tag:blogger.com,1999:blog-13501811090335234762024-03-12T15:03:40.239-07:00Why is American health care so expensive?The cost of health care in the US is higher than anywhere else in the world, and yet we are not healthier than our peer nations. In fact, in terms of such measures as infant mortality and life span, we don't measure up. Why is this? Many people involved in providing or receiving care have some pretty good ideas about what costs so much, and what we can do to reduce costs and improve quality. Sharing these stories is an important step in creating affordable universal health care.Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.comBlogger364125tag:blogger.com,1999:blog-1350181109033523476.post-15208409907403260412024-01-18T15:30:00.000-08:002024-01-18T15:30:04.343-08:00AI -- what it can and can't do for medicine<p> </p><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirnlOaSAjLQeOpGXUJaEkPG7oUfgxSJGFE3FcppY0nilyrolemBAZkzKgufrpks-6SM1opFNx8RF9ZY6qSLaN8wt9RmosMrVqEermzNSAHhBMzBY1MsS9AcZZyjyHFILAZxw6tDyqv3n95Vd1e3cq7Bizlzvt3yNwI3o6n5FgNbxDpNWii2iRCg74zTkk/s4032/IMG_0521.HEIC" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirnlOaSAjLQeOpGXUJaEkPG7oUfgxSJGFE3FcppY0nilyrolemBAZkzKgufrpks-6SM1opFNx8RF9ZY6qSLaN8wt9RmosMrVqEermzNSAHhBMzBY1MsS9AcZZyjyHFILAZxw6tDyqv3n95Vd1e3cq7Bizlzvt3yNwI3o6n5FgNbxDpNWii2iRCg74zTkk/s320/IMG_0521.HEIC" width="240" /></a></div>Artificial Intelligence (AI) has been on the edge of my consciousness as a great hope for solving many of the problems in clinical medicine for maybe a decade. In 2011 IBM created a program called Watson which was able to answer questions in plain English and search data sources for answers quickly enough that it beat 2 humans in a game of Jeopardy. After its success in a game show, the program was used to make a chatbot to help people buy diamonds, to write recipes for Bon Appetit and by various financial firms to increase profits. It also has healthcare applications, including diagnosis and treatment recommendations as well as decision support for imaging. But that's just Watson, which isn't the big name in AI right now.<p></p><p><b>ChatGPT came out in 2018</b> and by 2021 it was available to users. Last year I signed up for it and used it a little bit for what it seemed to be good for. I tried asking it questions, mainly medical ones, and I used it a little bit to generate text to explain complicated things to patients. My young family members told me it was great for writing emails, which I declined to do because I think I am just fine at writing emails. It was also going to be great for writing essays in general. Also blog posts, even ones in my style! That totally seems like cheating so I'll pass on that.</p><p>I liked the text generation a little bit, but stopped using it because there is so much good information already available to explain conditions that are relevant to my work, and I could never be sure the information that GPT spit out was accurate. When I go to a Mayo Clinic site or American Diabetes Association or an article from a journal I respect, the source of the information is clear and I even know what biases I might expect to see. If I copied text from these sources into a patient's note I could be confident it was accurate.</p><p><b>What is this "AI"?</b> Much of what we think of as AI right now springs from large language models which produce answers for us based on what humans have written and that is available to the program. This means that they are very good at writing cover letters or even college entrance essays, but not good at answering questions that haven't already been answered. Also, if the question we ask has an answer that has changed in the last little bit, that may not be reflected in the response. </p><p>My hope for AI with regard to diagnosis was that it would be able to identify variables associated with certain diagnoses that were diverse enough that my human brain couldn't see the connections. Like for instance perhaps a combination of features of a person reliably predict a condition. Maybe we could use information we normally gather in a patient encounter to more accurately determine what condition they have and use historical records to determine what treatment would work best. These obvious game-changers for my profession will not be solved by the AI that I have access to. What happened in the past to patients, including their diagnoses and treatments, has been based on such flawed and ever changing practice that, even if it were possible to collate and examine the myriad data points, the output would likely be garbage.</p><p><b>How about magnifying biases?</b> We have read about AI's tendency to perpetuate our historical biases. AI will definitely perpetuate our biases because neural nets which are the basis of AI train on data sets from the past. Neural nets look at massive amounts of data in order to be able to produce answers to our questions. If a chatbot produces an assessment and plan it will resemble all the previous assessments and plans it has read. If we have routinely <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/" target="_blank">underestimated the pain</a> experienced by people who are black (we have, see link) assessments of patients who are black produced by a chatbot will underestimate their pain. Even if an AI is just using numerical data to detect associations (vital signs, lab tests, presence or absence of symptoms), as it might if it were being used to diagnose disease, that data will be overwhelmingly based on people with better access to care. Diagnoses based on that information will be less accurate for patients who are socially disadvantaged. That doesn't mean AI and large language models would be completely useless, but it does make them less reliable. These problems will require remediation and in the meantime we will need to examine their conclusions in light of what we know to be our historical biases. </p><p><b>What we would really like AI to do is take care of the jobs we hate.</b> For instance, billing. Billing for our services is incredibly soul killing. Kevin Schulman et al from the departments of medicine and business at Stanford University wrote an <a href="https://pubmed.ncbi.nlm.nih.gov/37971721/" target="_blank">article</a> in JAMA about how AI will likely fail to relieve us of this burden because the problem is just too large. As I see it, ideally we would have AI just help us know what to include when we write our encounter notes (or make edits as needed) to allow us to bill for what we do. Then it would produce the billing documentation and we'd be done. No billers, no us trying to figure out the proper codes, just work, then get paid. But that's not going to be so easy. </p><p>According to the authors' research there are over 300,000 health care plans in the US, about one for every 1000 people and each of them may have different benefits and documentation requirements. There are up to 14 steps in processing each payment. There are nearly 600,000 different codes used to describe different services and the prices associated with these codes are negotiated differently so there are around 57 billion prices for all of these. This complexity funds (meaningless) jobs which (nevertheless) keep families fed and maintain the perceived need for health insurance corporations. The conflict between providers of medical care who want to be paid as generously as possible and health insurance companies who want to pay us as little as possible is longstanding and perpetuates the complexity. If AI just completed our documentation, which would be nice, I suspect insurance companies would quickly respond by requiring more information, especially since AI is known for making things up. Complexity is at the heart of the huge costs and effort related to billing and will need a legislative rather than a technological solution.</p><p><b>So what is it good for?</b> AI is extremely useful in discovering patterns in data. That can be and is used in research, helping discover what medications work for what conditions among other things. That is AI in the broader sense, not large language models such as ChatGPT. Large language models are good at writing and doing research on questions which use databases of text. They can definitely write emails and make recommendations regarding what to eat when you have the stomach flu. They may be able to produce notes by listening to what people say during a medical encounter. That would be amazing, but would definitely require editing. There will undoubtedly be some ways they can make billing and referrals easier, if only by producing excellently worded correspondence. Eventually artificial intelligence will overcome limitations and we will probably simplify processes to make this possible. </p><p>It will be interesting to see what the next 10 years brings. I suspect I will be beyond caring when AI takes all of our jobs, kills most of us and turns the rest of us into slaves to produce the massive amount of electricity required for the upkeep of our robot overlords.</p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-88397936395704321832023-03-10T19:31:00.004-08:002023-03-11T16:46:54.928-08:00Guess who finally got Covid?<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOqJrLtUylWFuaKA-eI8inltmMgOwgRQCdZ4grEegW_eHrbr31nBWlVyDne_isR54lopQy4r48mNakrSMr_BBdAMkIx4xT2QhIdRiNCu7CjwhzvvG5hZOssng_m51OCG8AXeP3ILSRbr1uoIvYayaAbvrKgCz6VOg74YEl0Pd_TwoXvGAQEI2JCn-R/s4032/IMG_1748.HEIC" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOqJrLtUylWFuaKA-eI8inltmMgOwgRQCdZ4grEegW_eHrbr31nBWlVyDne_isR54lopQy4r48mNakrSMr_BBdAMkIx4xT2QhIdRiNCu7CjwhzvvG5hZOssng_m51OCG8AXeP3ILSRbr1uoIvYayaAbvrKgCz6VOg74YEl0Pd_TwoXvGAQEI2JCn-R/s320/IMG_1748.HEIC" width="240" /></a></div>The earliest cases of the novel coronavirus seem to have been in Hubei Province, in the city of Wuhan in China, possibly in November of 2019. The virus shares a family name with other more common viruses that are known to cause upper respiratory infections, such as the common cold. I won't go into Covid's origins, other than to say that there has been lots of obfuscation about them and I look forward to seeing the original streaming video series of the pandemic in about 5 years when perhaps the truth will be accepted fact.<p></p><p>I first heard about this new virus before I went to South Sudan for the last time in early 2020. I wasn't worried. There had been flu pandemics in my lifetime and we had muddled through. How bad could it be? People were starting to wear masks in the airport, which I thought was silly. As it spread to western Washington state, it looked like it might be more serious than I had predicted. Then it got awful in Europe, then finally the US became a disaster of full hospitals and patients dying in hallways. I enthusiastically got my first vaccination on 12/21/2020. </p><p>I continued to work in our community clinic. We switched to mostly telehealth and I worked from home 2 of three 10 hour days, visiting with patient on the phone or through a video interface, with one day still spent in clinic seeing patients in person. We wore masks and tried not to share offices, changed airflows and avoided seeing people with respiratory infections in the clinic. We still did see our share of "surprise Covid" patients who revealed their symptoms after we had been in a stuffy little office together for several minutes with their masks gaping around their faces, but miraculously I did not get sick. Our office even had special paid Covid days off, outside of our usual paid time off so employees had no reason to work sick. We stopped having office parties. The lounge where we ate had a limit to the number of people who could be there. I stopped going to restaurants or parties or church or anything that might expose me to lots of potentially infected people. I stopped singing with my singing groups. I religiously wore masks whenever I was inside with anyone other than family and switched to KN95's when they became available. I got all of my vaccinations and then some. All of these things were very effective. Neither I nor my husband got Covid. Or any other infectious disease, for that matter. </p><p>Lately I have been relaxing my masking more. After getting my first vaccination I decided that I would not worry about masking with close friends or family, unless they were sick. I did continue to mask in other situations. But in the last few months I sometimes go to stores with no mask, if they aren't too crowded, and sometimes at the gym, while doing cardio, with a fan blowing the air away from me, I don't wear it. In the office I no longer nag my patients to wear their masks properly in the examining room if they are not having Covid symptoms. </p><p>A week ago Tuesday I had a bit of a sneezy nose. Nothing very unusual, but I took a Covid test just to be sure. It was negative. No symptoms at all on Wednesday. By the end of the day Thursday I had a bit of a sore throat and my skin felt sore. I took another Covid test in the evening. It was negative. I looked at the public health websites and found that both flu and Covid were at a very low level in our community. I wondered how we would really know, since mild cases of both are never reported and in Idaho at least, reporting of positive home tests is not encouraged. But I was reassured. My throat was still sore Friday morning, so I tested again, just to be sure. It was negative. So I went to my physical therapy appointment. It was a great appointment and I decided not to have my hip replaced after all, which was incredibly valuable. I masked with my handy dandy well fitting KN95 mask during our time in the small office, though my therapists did not. I got home, told my husband I definitely had something viral and if he liked I would relocate to the little house in the backyard. He said yes, please. </p><p>I spent a painful but not horrible day in bed reading books and cancelling my hip replacement. The next morning at about 3 AM when my sore throat told me I had to get up and take some tylenol I also took another Covid test. It was positive. Such a bold red line! And so quickly! </p><p>I found that 440 mg of naproxen twice a day with up to 4000 mg acetaminophen daily in doses of 1000 mg every 6 hours kept my throat tolerable. At least it did for awhile. When it stopped helping as much I decided I might as well try Paxlovid, which would definitely fight the virus. Paxlovid is, so far, the most effective drug to fight mild to moderate Covid and is indicated for anyone at higher risk. I consider myself young and healthy, but I am significantly over 60 and have hypertension which does put me at slightly higher risk. Also Paxlovid is harmless (other than a bazillion drug interactions) and not in short supply. So I called in a prescription of that for myself. The number of pharmacies that carry Paxlovid is limited, possibly because of low reimbursement along with difficulty getting it, but I was able to find a pharmacy that had it (Walmart.) </p><p>I hoped with Paxlovid my sore throat would rapidly feel better. I longed for that feeling when the antibiotic kicks in and the problem melts away. Unfortunately that was not to be. I don't know if I would have kept getting sicker without Paxlovid, so I am glad I took it. But I do understand why it isn't a blockbuster drug.</p><p>Paxlovid is a combination of ritonavir and nirmetralvir. The nirmetralvir is a protease inhibitor, reducing the virus' ability to cleave its proteins adequately, thus reducing its ability to reproduce and cause disease. Ritonavir is a drug, first used to treat HIV, which actually slows down an enzyme in the body that breaks down nirmetralvir. A dose of Paxlovid is 3 tablets, two 150 mg nirmetralvir and one 100 mg ritonavir. These pills are pretty huge and difficult to swallow with a sore throat, and man was my throat sore. And within about 30 minutes of taking them, my mouth developed a horrible bitter taste that was there for 11+ hours, just starting to fade when it was time to take it again. So the pills wouldn't get stuck on their way down, I took to coating them with butter and swallowing them with a full glass of water and then some bulky food, like oatmeal or bread. There are various solutions online for Paxlovid mouth, but let me add mine. Chicken. The flavor of chicken-in soup, baked, on pasta, whatever- cleared out the taste, at least while I was eating. </p><p>The cough and sore throat made sleeping or being comfortable at all pretty challenging, but throat coat tea with honey was a good adjunct to over the counter pain killers, and I found that a tiny dose of the ten year out of date hydrocodone that I was able to find in my medicine kit was magic for cough. Half of a 5/325 pill of hydrocodone/acetaminophen kept my cough well and truly gone all night and much of the next day, without significant side effects. It did not, however, help with pain, strangely enough.</p><p>Once I started to feel better, around day 4, I started to test myself again, hoping to be allowed into the main house without a mask. Turns out I was still vigorously positive for Covid antigen until the start of day 6. </p><p>I don't know if there will be any long term bad effects. So far, I seem to be back to nearly normal activity level and my brain seems the same. I have a little cough which is annoying, but that's it on day 8. </p><p>This is really just the story of finally succumbing to covid, without any earth shaking wisdom. I guess my distilled take home points from the experience would be:</p><p>1. Paxlovid tastes really bad, but other than that and the huge pill size, we should be adopting it more widely to reduce the severity of Covid. All things chicken are a good antidote for the bitter taste.</p><p>2. Acetaminophen and naproxen aren't too bad for pain relief. We read all those articles insisting that non-opiate pain relievers are as good as opiate combinations, and I'm thinking this is really true, at least for some kinds of pain.</p><p>3. Hydrocodone is a long acting anti-tussive (stops a cough.) It doesn't take much. It comes in a cough syrup as well, but it's the opiate, not the preparation that calms the cough.</p><p>4. I'm not sure we can trust information about community transmission of Covid at this point. The new variants are extremely transmissible and most people are either not testing for Covid or not reporting home tests.</p><p>5. It can be a long time after symptoms start that a Covid test comes up positive. Keep testing if you need to know!</p><p>6. Being vaccinated and not getting Covid during those really awful early days are gifts for which I am truly grateful. Being a doctor and having a safe and comfortable place to be sick are privileges not available to the vast majority of the world's population and I do recognize how lucky I am! </p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-16867739950660132152023-01-01T20:58:00.004-08:002023-01-01T21:06:18.212-08:00Nurse Practitioner Scope of Practice and the AMA<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijOtRZR3xjJ4-9Pq3JcfdX_LiGsksd7vB8kAUYWhjJIcMJFdsQnNQTkfYhaqfS-O0sVMX61zF_6uM3NSRLAcjXbAjWQ8DEBq5IR8u6duJ-EMJ1QhLYUpXWLdomP7x3fyI_5MsUizNglfkdMlMDhqahujAHSNyfiU3ScJn2hm4Om-V0Ag8yzm6waQR6/s4032/IMG_5505.HEIC" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijOtRZR3xjJ4-9Pq3JcfdX_LiGsksd7vB8kAUYWhjJIcMJFdsQnNQTkfYhaqfS-O0sVMX61zF_6uM3NSRLAcjXbAjWQ8DEBq5IR8u6duJ-EMJ1QhLYUpXWLdomP7x3fyI_5MsUizNglfkdMlMDhqahujAHSNyfiU3ScJn2hm4Om-V0Ag8yzm6waQR6/w240-h320/IMG_5505.HEIC" width="240" /></a></div>I have been working at CHAS Health, a community clinic serving Eastern Washington and Northern Idaho for a little over 3 years now. This is a different experience for me than my prior 35 years of practice for many reasons. CHAS originally started as a small clinic associated with a homeless shelter and provided mainly care of people without health insurance. It has expanded, but it still serves primarily people with various kinds of barriers to getting health care. CHAS provides support for people who are at risk of losing their homes and who have trouble paying copays. We are happy to take care of people with drug and alcohol problems, people who have just gotten out of prison, people who have trouble following recommendations from health care providers and may have been "fired" from other practices. We also see people who don't have any of these challenges, but just happen to like us. We are set up to make it possible for all sorts of people to navigate the very fragmented and expensive system that is American Healthcare.<p></p><p>When I first started to work at CHAS I was surprised to find out that I wouldn't actually have an office and I would probably be moving from one desk to another depending on what space was available. In my previous offices I always had my own desk with drawers that I put things in that I would use to take care of patients, a bookshelf to hold my favorite texts, wall space to put up pictures of family and copies of diplomas and medical licenses. I worked with RN's who would assist with procedures and could give intravenous treatments. I shared on-call responsibilities with a number of other doctors with nearly the same experience I had. At CHAS we use medical assistants instead of RN's, who can do many but definitely not all of the things RN's can do and have less independence than my previous nurses. (We did get a nurse finally but we share her and she has very different responsibilities.)</p><p>The biggest difference is that CHAS is primarily served by Nurse Practitioners and Physician's Assistants as the providers rather than MD's. There are a few MD's, but it is really difficult to recruit MD's for our practice. There are more Nurse Practitioners and PA's in the job market and they are apparently less picky about certain things. They also have fewer years of training than doctors and took on less responsibility in the process of getting their degrees. Some have many years of experience, having been nurses before but none had the baptism by fire that is common for MD's. (I recall as an intern taking care of a whole medical floor of acutely ill patients in the hospital, getting 4+ new admissions from the emergency department and making decisions completely unsupervised countless nights, presenting the cases in the morning to the attending physician and working until sign-off at 6 PM the next day.) I don't recommend the baptism by fire thing, but it does teach you medicine. That scenario was repeated, with gradually increasing levels of experience, for 3 years before I was released to practice independently. </p><p>So right out of training I had some skills. Not to say that a person needs to be able to juggle the needs of sick and dying hospital patients in order to take good care of clinic patients. Nevertheless there is a difference in the backgrounds of NP/PA's and MD's, related to level of responsibility and sheer hours of patient contact as the main decision maker. That said, the backgrounds of mid-level practitioners can be more helpful to outpatients than that of certain MD's. <a href="https://pubmed.ncbi.nlm.nih.gov/28234756/" target="_blank">Studies</a> do not show that MD's do a better job of taking care of patients in community clinics that NP's or PA's. </p><p>More NP's and PA's are licensed each year than MD's. Looking through various internet sources, it appears that over 36,000 new NP's and 20,000 PA's are licensed each year and new physician graduates add up to fewer than that, around 20,000. MD's and DO's (Doctor of Osteopathy, a pathway very similar to MD) actively practicing medicine number a bit over 1 million in the US. NP's and PA's add up to just under 500,000, since those two certifications have not existed for as long. </p><p>An MD or DO degree takes 8 years to complete after finishing high school (a college degree then 4 years of medical school), and is followed by a required residency program that takes 3-7 years depending on the specialty. When I did it, there were no restrictions on the number of hours we spent at work during our clinical years and residency, which meant that we spent vast amounts of time in the hospital. Weekends had virtually no meaning after the first 2 years. It is incredibly competitive to get in to medical school, so students need to have stellar grades and scores and have done a few extra things that show how super special they are just to be admitted. Residency is also competitive: some people complete their MD only to fail to get a residency. This is a huge hurdle to starting practice as a doctor and a colossal waste of time, money and talent.</p><p>Becoming a doctor in the US is an unnecessarily difficult process. </p><p>The British system, followed by many other countries in the world, involves getting a Bachelors degree in medicine. This degree requires around 6 years after high school and leads to a degree as a physician and surgeon. It is possible to practice medicine after that, though I believe most people do a residency. After being qualified to be a physician they are called "doctor" though they do not have a doctorate degree. It is possible to do further academic or scientific work and gain a doctorate in medicine or science, but that is not common or required. </p><p>A nurse practitioner in the US usually gets a four year Bachelors degree in nursing (occasionally 2 years if it is an accelerated program), spends a few years being a nurse (sometimes many years) and then does the 2-4+ year program to be an Advanced Practice RN. This can lead to a practice as a midwife, nurse anesthetist (like an anesthesiologist) or a family practice NP. Physicians assistants finish a regular undergraduate degree (Bachelor of arts or sciences), usually does some kind of medical or science related job for a few years, then applies to a program that takes 2 years to complete. Both NP's and PA's can do residency programs before going to work.</p><p>The AMA (American Medical Association) is involved in advocacy for physicians to various agencies, including federal and state governments. I just recently saw that their focus this year involves pushing back against "scope creep." By this they mean trying to make sure that nurse practitioners can't practice independently of doctors. There are 26 states (including Idaho, where I practice) that are considered "full practice" states for nurse practitioners. They can open their own clinics and can practice and prescribe independently. There are still some restrictions, including hospital work and (strangely) prescribing certain durable medical goods. The AMA continues to lobby enthusiastically against more states joining the "full practice" majority. </p><p>I recently read an <a href="https://www.acpjournals.org/doi/abs/10.7326/M22-2196?journalCode=aim#.Y2EN21jOPm4.twitter" target="_blank">opinion piece </a>by Robert Doherty in the Annals of Internal Medicine. Mr. Doherty worked for decades at the American College of Physicians in health policy and knows his stuff. His essay "In the These Uncaring Times, Will Physicians Lead Us Back to our Better Angels?" holds nothing back in encouraging doctors to be involved in the fight against discrimination against vulnerable and disadvantaged people, to work harder, even to be involved in civil disobedience. He feels the US is regressing, with corporate profits made more important than "the dignity, health and lives" of Americans. He mentions that we need do more to reduce harm to patients, rather than focus on issues such as "scope of practice." Working on scope of practice means pushing back against the power of nurse practitioners and is what the AMA is doing. </p><p>The clinics where I work rely heavily on NP's and PA's to provide primary care to our patients. Without them, CHAS would simply be unable to function. In my position as an internal medicine consultant, I review many charts and observe many practice styles. There is huge variability in the level of competence and completeness and also in the complexity of patients. I am in awe of some providers' care and other times things are clearly missed or done wrong. Sometimes I notice that I have missed something that another provider would have noticed. Care is obviously better when providers are able to ask each other questions, and when they have diverse backgrounds. It is good when MD's are part of a mix of providers. But it has been extremely difficult to recruit MD's for our clinics. Specialty care, such as gastroenterology, rheumatology, neurology, oncology and surgical subspecialties is almost always provided by MD's outside of our clinic. Our patients often wait in excess of 6 months to see these specialists, which is both dangerous and embarrassing. The cardiologists in our area use nurse practitioners to manage patients with heart disease and we are generally able to get these patients in much more quickly because at these offices there is adequate staffing. In our community there are simply not enough MD's.</p><p>So what should we do about the increasing numbers of NP's and PA's providing care for patients? I think we should welcome them, support them, mentor them and learn from them. We MD's should have a more humble perspective, realizing that the US system is different than most of the rest of the world and that our very arduous educational path for producing doctors has not created a system that is more effective and equitable than places that do it differently. </p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-37140651398079056572022-07-03T17:39:00.001-07:002022-07-03T17:42:27.932-07:00Why are new drugs so expensive? The absurdly high cost of newly marketed brand name drugs.<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisLVLpfVUwvaqF47ANuQkc8ogNAkkDTpAdbSQHMtuXWQPgte9Gj4Okv-ULZGFX3oXKmA9b9qPs813Fi13EXZGSTxMchqK1F5DINZjoyDePwW1yeertVw0_P6j83eQre1CxKluLbhq-wp4bn4yBjHPy9hv0icp0qVrzh4Z14SiFE8b6oXzuvwEhqhc5/s4032/IMG_9568.HEIC" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisLVLpfVUwvaqF47ANuQkc8ogNAkkDTpAdbSQHMtuXWQPgte9Gj4Okv-ULZGFX3oXKmA9b9qPs813Fi13EXZGSTxMchqK1F5DINZjoyDePwW1yeertVw0_P6j83eQre1CxKluLbhq-wp4bn4yBjHPy9hv0icp0qVrzh4Z14SiFE8b6oXzuvwEhqhc5/s320/IMG_9568.HEIC" width="240" /></a></div>In the JAMA (Journal of the American Medical Association) there are occasionally amazingly interesting snippets of information, not long enough to be articles, written as letters. In the early June 2022 issue, a <a href="https://jamanetwork.com/journals/jama/fullarticle/2792986" target="_blank">letter </a>entitled Trends in Prescription drug Launch Prices 2008-2021 was an eye opener. I have known for a long time that new drugs come out with high prices. In general, for this reason, I rarely prescribe new drugs unless they substantially improve my patients' lives <u>and</u> are covered by their insurance. The costs of new drugs are absolutely beyond what anyone but the most fabulously rich people can afford. <p></p><p>Harvoni, a drug to treat a very common form of blood borne hepatitis that is responsible for a substantial proportion of cases of liver failure, costs about $90,000 for a 12 week course.</p><p>Ozempic, a weekly injection that works great for type 2 diabetes and is very effective in helping people lose weight, costs over $1000 per month.</p><p>Humira, an injection sometimes given twice weekly for conditions such as rheumatoid arthritis and Crohn's disease, costs up to $9,000 per month.</p><p>Ocrevus, a twice a year infusion for multiple sclerosis, costs about $37,000 per treatment not counting the associated infusion center services.</p><p>Entresto, which is becoming standard of care for treatment of severe heart failure, costs around $600 per month. </p><p>An Anora Ellipta inhaler, for asthma or COPD, costs just shy of $500.</p><p>Invega sustenna, a monthly injection for treatment of some of the symptoms of schizophrenia, costs nearly $2,500.</p><p>This list is just a handful of random drugs that people can't actually afford but frequently need. </p><p><b>So--this JAMA letter.</b> It says that the prices of new drugs have gone up exponentially since 2008. In 2008 the median launch price per year for new drugs was $2,115. In 2021 it was $180,000. The most expensive of these drugs were for rare diseases and for cancer, but there are also drugs for urinary incontinence, a cream for acne (just a combination of two chemicals available over the counter) and a new birth control pill. The best deal looks like it might be the birth control pill, which costs around $200 per month (it is nothing special.)</p><p>Reading these prices makes a person shake her head in disbelief, or say something best not said in the presence of children. And then ask "why?"</p><p>The best answer is "because they can" but it ignores the more important questions of how it got this way, why we permit it to continue and what we should do about it.</p><p><b>How did it get this way? </b>In my memory, after over 30 plus years of practice, it seems to have gotten this way very slowly and gradually. I remember the release of some amazing drugs that changed the outlook for various conditions. Prilosec to treat heartburn--a drug that actually worked to reduce acid in the stomach. It was amazing. Prozac--an antidepressant that didn't make people overweight and sedated and brought them reliably out of episodes of depression. Certain antibiotics that could be taken once a day rather than several times and worked as well as injections. </p><p>When these came out they were expensive and insurance companies were loath to pay for them, but they weren't that expensive. Then came some new cancer drugs and some drugs for psychosis that were more expensive. If they were truly necessary they were paid for by insurance or by patients. Eventually there came the 5 figure drugs. It seemed unlikely that anyone would use them, but they eventually became part of the tools of specialty physicians. Then there were more. And here we are. The most expensive drug in history is over $2 million, a one time gene therapy to treat spinal muscular atrophy, a fatal disease of children.</p><p><b>Who does this hurt? </b>It is often nice at this point to tell a story of someone who is impacted by this issue, a person who dies of a disease perhaps because of inability to afford the medication. There may be many, but I don't know their stories. Generally when my patients are diagnosed with cancer they become eligible for some kind of coverage for medications that means they don't pay anything. The drugs might be supplied for them under a compassionate use program from the drug company or they end up on Medicaid, the state sponsored comprehensive healthcare insurance system, that pays for needed treatment. </p><p>These safety nets do not, however, necessarily protect seniors. In an <a href="https://www.nejm.org/doi/full/10.1056/NEJMp2202726" target="_blank">article</a> in the New England Journal of Medicine entitled "Your Money or Your Life," out of pocket costs for patients on Medicare with cancer were evaluated. For oral medications rather than infusions, the patient's share of the cost is often huge, around $12,000+ dollars. These drugs are actually both more convenient and less expensive overall, but are paid out of Medicare part D, which leaves more of the cost to the patient. I imagine there are people dying because of inability to pay or unwillingness to spend their entire nest egg on a drug.</p><p><b>Why do we allow prices to be so high? </b>The safety nets are part of the problem. The fact that drug companies provide medications via coupons or compassionate use, and insurance companies pay for them after physicians fill out endless prior authorization forms means these costs are, in fact, what the market will bear. </p><p>Another reason for high costs of the very new drugs, ones that do not resemble other drugs at all and solve whole new problems, is that drug companies will try to recoup their costs by charging the few patients who need these drugs a very lot of money, which insurance companies will often cover because there aren't that many patients who need them. </p><p><b>But the real reason </b>for these high prices is that they are part of our economic ecosytem. Pharma is doing great. Drug companies outperform the stock market in good times and even more in economic downturns. These high prices, to the extent that they don't lead to slowing in sales, support an industry that supports a vast number of jobs and contributes significantly to our gross domestic product. Costs like this are so huge that they are most often borne by the government, and so they directly lead to tax money being pumped back into the economy. There are also the many places that such huge amounts of money leak out of what might appear to be a closed system into other industries, including the many that support the whole process of turning scientific ideas into drugs and prescriptions into pills in patients' hands. There are also some weird ways that seemingly arbitrarily and almost comically expensive drugs support nearly unrelated activities. The only one of these that I am personally familiar with is how my community health center's pharmacy supports its sometimes un-reimbursed care for our patients living in poverty.</p><p>We have a pharmacy right in the clinic, which is great. I get to talk to pharmacists about patients and figure out the best way to get them treated, including choosing the right drugs and making sure patients can afford them. This pharmacy provides all sorts of medications inexpensively to our patients, which they source at discount prices. They are then reimbursed by third party payers at a higher price. </p><p>One drug I mentioned above, Humira, is available to our uninsured patients whose income puts them in the most favorable tier of our sliding scale at a cost of about $5 per month rather than the usual $9,000. I'm not sure how much money each of these transactions nets the pharmacy, but it is substantial. Because of this, as well as grants and such, we can happily provide care for people who have no ability to pay us. This <a href="https://en.wikipedia.org/wiki/340B_Drug_Pricing_Program" target="_blank">340b</a> program has been in existence for many years and also applies to some hospitals which serve low income populations.</p><p><b>How could we bring these prices down? </b>Certainly some countries negotiate drug prices with pharma manufacturers. Governments can choose not to participate in payment for drugs which are too expensive and don't significantly improve treatment for a condition. The US does not do this. We could fully fund pharmaceutical labs to produce drugs which would then be sold at a reasonable price, allowing government insurance such as Medicare part D and Medicaid to avoid these high costs. </p><p>But high prices of drugs end up putting money into so many pockets that there is not much incentive to make these changes. Many of these drugs eventually become less expensive as they lose their patents and generics come around, or so we tell ourselves. In fact, many of these very expensive drugs remain mostly high priced for over a decade after they come out. Drug companies also seem to pace the release of new drugs so that something slightly better comes out of the pipeline just as a really good drug becomes affordable. Sometimes patents are prolonged by slightly changing formulations or dosages or indications.</p><p><b>Is there actually a problem? (spoiler alert: yes.) </b>If low income people can get expensive drugs and if the money eventually comes back into the economy anyway, is there really any reason to battle the high cost of drugs? Yes, there is. Insurance companies do end up paying these costs, and that results in increasing insurance costs to everyone. People with Medicare and private insurance find themselves responsible for paying a portion of some of these high cost drugs, exacerbating poverty and limiting quality of life. The patient's share of these crazy high costs can be huge. All of the jobs I mention and contribution to the GDP and the stock market don't benefit most people and certainly don't benefit the people who are most harmed by high drug prices. </p><p>Inflated drug costs are borne in large part by the government, via insurance like Medicare, Medicaid and through the VA. So money is going into the government via taxes and out as payments to drug companies, redistributing money meant to pay for things that benefit everyone, to wealthy corporations. We elect our government at least partly with an expectation that they will spend our money wisely, for things that give us good value. I would argue that many prescription drugs do not constitute good value. Some insurance companies, private or government sponsored, simply refuse to pay for expensive medications, frustrating doctors and patients. Perhaps working to ensure drug prices are not excessive would be a better way to get the excellent health outcomes offered by pharmaceutical advances rather than allowing them to be unaffordable.</p><p><b>The incentive to do something</b> about high drug prices will have to come from consumers demanding some kind of governmental regulation. Perhaps this will be by allowing government to negotiate drug prices with pharmaceutical manufacturers--since that works in other countries. Though their profits are obscene, I do not fault drug companies for being successful. They do produce some pretty amazing medications, including recently an mRNA vaccine for Covid that saved millions of lives, a class of drugs for cancer that can halt or cure certain advanced cancers and some newer drugs for diabetes that can also prevent heart disease. They need to be able to do what they do as efficiently as possible and without being regulated into failure. The situation as it now stands, however, is not supportable.</p><p><br /></p><p><br /></p><p><br /></p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com2tag:blogger.com,1999:blog-1350181109033523476.post-11378777555141927252022-06-27T17:16:00.003-07:002022-07-03T17:41:19.319-07:00We need to talk about abortion: Roe v. Wade and its overturn<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikSndIDmdtVsS9Or4u-wFZYMqZ4BaodnPcW5L1NlP3U5_L8xer50ClXLlPSxrHYdrEnU6fkxJyFHSzgDghyOxcK4HjdNwv9Wcrj3PBE0uLj8h0pTyJEQPtkqA8M6GkQ53GmFMTemdZM2W1R1kLgbt4SDIxtX_vNW8RFx-WeIPAntPj94KlVN7hL9As/s4032/IMG_9535.HEIC" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="3024" data-original-width="4032" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikSndIDmdtVsS9Or4u-wFZYMqZ4BaodnPcW5L1NlP3U5_L8xer50ClXLlPSxrHYdrEnU6fkxJyFHSzgDghyOxcK4HjdNwv9Wcrj3PBE0uLj8h0pTyJEQPtkqA8M6GkQ53GmFMTemdZM2W1R1kLgbt4SDIxtX_vNW8RFx-WeIPAntPj94KlVN7hL9As/s320/IMG_9535.HEIC" width="320" /></a></div><br />On June 24, 2022, the Supreme Court overturned Roe v. Wade, the 1973 case that provided women with a legal basis for a right to get an abortion. (Full text of opinion and dissent <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf" target="_blank">here</a>--pay attention to page 148 to the end, the dissent.) This will make it difficult and dangerous for women in states whose legislatures oppose abortion to terminate a pregnancy. Many women, regardless of what state they live in, now believe that it is illegal for them to get an abortion. The amount of misinformation going around regarding this subject has been large, and now it is frustratingly larger.<p></p><p>In the face of all this confusion, I would like to praise the JAMA (Journal of the AMA) for publishing a very nice, straightforward <a href="file:///C:/Users/Janice/Downloads/jama_cohen_2022_it_220004_1654120396.89601.pdf" target="_blank">article </a>about how to provide medical abortion in the first 10-11 weeks of pregnancy. By medical, I mean pills. There is a pretty simple combination of a couple of common medications, one to reverse the effects of progesterone and the other to permit the cervix to open to allow passage of the products of conception. The effect is a very heavy period, with cramping and bleeding that can last a few weeks.</p><p>But the whole concept of abortion and how it has been treated in the US is fraught with difficulty. Roe v. Wade allowed that abortion was essential and that is should not be substantially regulated by the government in the first trimester and that prior to viability (a moving target, but somewhere toward the end of the second trimester) the government could not regulate it other than to provide for the health of the mother. As a fetus gets more mature, abortion gets more dangerous for the mother, and carries more emotional weight. At 15 weeks, far before it would be able to survive outside the uterus, a fetus is about the size of a small mango and looks like a baby. Having done many ultrasound exams on mothers in their first and second trimesters, I'd have to say that the little critter swimming around in the womb isn't nothing and choosing to end its brief journey would have to be heart wrenching. For both the mother and for the doctor performing the procedure. </p><p>But women are not incubators and shouldn't be treated as that. Carrying a baby is a huge responsibility, changes ones body forever and often completely waylays ones education and life path, even if the mother decides to give up the baby for adoption. And if abortion were murder, which many anti-abortion/pro-life activists assert, does it even make sense that all of the women who decide to terminate a pregnancy and all of their doctors who provide that service are murderers? It just doesn't make sense. Getting an abortion is difficult and painful and women don't actually want to do it. When they do this difficult thing, it is to preserve their future, and in some cases their ability to have children for whom they can create a good home and a happy childhood. I see no reason to believe that state governments are more able to make a correct moral and ethical decision than individual women who are pregnant.</p><p>I am living in a state with a "trigger law" banning abortion after Roe v. Wade is overturned. The governor released a message saying that we need to support women more when abortion is no longer legal (which he is happy about), including allowing them time to take care of their babies and children and providing social support systems and family planning (I assume he means birth control.) We always needed that. If we had the ability to support young people in this way after my state bans abortion, why didn't we do it before? Was my state just being vindictive to young women? Encouraging women to get abortions because carrying a baby to term would be really hard?</p><p>But back to the JAMA article and more information I have been picking up about medical abortion. The basic facts of the process are that a women who is less than 77 days pregnant can take 200 mg of mifepristone, followed by an 800 microgram tablet of misoprostil, either dissolved in the mouth or in the vagina. These medications are easily available. Misoprostil has been used for years to protect the stomach from the irritating effects of anti-inflammatory drugs such as ibuprofen by reducing acid production and bolstering the protective mucus layer in the stomach. It is also commonly used for cervical "ripening" when inducing labor. Mifepristone, initially released as RU 486, in also useful in treating uterine tumors and Cushing's disease. In states where abortion is legal, these drugs can be prescribed by a patient's doctor and covered by insurance. In states where abortion is prohibited, women can still buy the drugs online, with advice of a doctor, and the cost is not very high. Since the US mail is not regulated by the states, women should maintain the right to use a service like this. This does require that women be very tuned in to their cycles so that they can identify pregnancy early if they need to terminate it.</p><p>For now, there are good reasons to believe that this pill option for terminating a pregnancy will remain an option for the vast majority of women. But there is also room for doubt. States could pass laws making it illegal to obtain pills for use in a woman's own home. A congress with a particularly strong desire to control women's lives could pass a law making abortion illegal nationwide. Those are some chilling scenarios.</p><p>For now, though, what I see as the biggest impediment to women, especially those who are young or living in poverty, in getting the care they need in early pregnancy is misinformation and unwillingness to talk about these issues. I have hesitated to write about it, because I worried that strong feelings on both sides of the issue would reward me with the internet's version of hate mail. But that nice brief informative article in JAMA gave me courage. Those of us with useful information to share should do that. The shame some people feel associated with activities that result in unintended pregnancy stifles conversation and puts women in grave danger when it comes to protecting themselves from pregnancy complications, sexually transmitted diseases and sexual violence and coercion. We need to talk about these things.</p><p> </p><p><br /></p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com3tag:blogger.com,1999:blog-1350181109033523476.post-63325608851879939922022-05-09T22:24:00.001-07:002022-06-26T22:01:31.734-07:00Physician retirement--questions, thoughts, considerations...<p></p><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCTBMzqWbhDy9_ctCmePXiHuQhApIxX6o24yG5Uz8SdxnviQo23AR80OQoQk3T1QoL-o6Q7FfT2tLIdf9wYT1s-2ldTpc2HV02bjstT0naLU2k_Dn_AFX22ZNnOwKv5ChJFv4hl9nT_OVXUw3QkGmzGGf4W2APVJdodDD1C5ZUSt6Asf1qZu38Gcs5/s4032/IMG_9385.HEIC" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCTBMzqWbhDy9_ctCmePXiHuQhApIxX6o24yG5Uz8SdxnviQo23AR80OQoQk3T1QoL-o6Q7FfT2tLIdf9wYT1s-2ldTpc2HV02bjstT0naLU2k_Dn_AFX22ZNnOwKv5ChJFv4hl9nT_OVXUw3QkGmzGGf4W2APVJdodDD1C5ZUSt6Asf1qZu38Gcs5/s320/IMG_9385.HEIC" width="240" /></a></div><br />I have been a practicing physician since finishing medical school in 1986. The year after that, I started my internship at the Johns Hopkins Hospital on the Osler medical service. I remember how excited I was about my salary of $17,000 that year. I called my mother. She was so proud. It was plenty to cover my food, apartment, gas for my VW Rabbit and essentially nothing else since I worked all the time.</div><p></p><p>By the time I finished my medical residency I was 28 years old and lived in Seattle where I was able to buy a house with my boyfriend (now husband) who was a scientist in a company that paid him a decent salary. My first job out of residency was with a healthcare cooperative, doing primary care and consulting internal medicine. After 4 years of that, I moved to rural Idaho where I have been ever since. For 17 years I was a "traditional internist" meaning I took care of my own patients in the office, took care of them when they were admitted to the hospital and provided some other services for the hospital and community as needed. I was on call every third or fourth weekend for myself and my partners and most evenings for my own patients. I was part of a larger clinic, but we were not salaried, keeping what patients or their insurance company paid for our services minus about 50% for overhead related to administration, billing, supplies and building costs. Primary care was not highly paid and I worked 3-4 days a week, so my earnings didn't go up much at all over the course of my career, which was actually fine. I lived close to my work--could ride a bike or walk when the weather was good, even skied to work a few times! No complaints. Still, it was a lot of work and a lot of responsibility and I fantasized almost every day about retiring, despite the fact that retirement was clearly decades away. As I fell asleep, I would think, "I will retire tomorrow and just lie in bed and read books." </p><p>In 2011, I decided I was due a sabbatical and quit my job to learn new things, do locum tenens in 5 states, refurbish my internal medicine knowledge base and do some international medical work and teaching. Eventually I also took a position at my home hospital as a staff hospitalist, in addition to away work. My jobs were intense, well paid and I had significant stretches of time off. Many of my locum tenens assignments as a hospitalist were in places where the hospital system was dysfunctional and the workload high and most were far enough away from home that I slept in a hotel or airbnb and spent a day on either side of my 7 day work week just in transit. I learned a ton, met lots of people and provided good service, but it was exhausting and stressful. By 2019 I was done. </p><p>Since then I have been employed as a consulting internist at a couple of community health centers in my area, 30 hours a week, 3 ten hour days plus commuting. (Also I teach ultrasound in my spare time.) I no longer take care of patients in the hospital and I do not take call. I get a salary and benefits. It is no longer grueling, only occasionally intense, and I still get to do what I love, which is see patients and work on solving their problems, relieving their misery and sharing their successes. Occasionally there are corporate bureaucracy related frustrations and I am not my own boss. But the main thing that creates tension (and we all know that tension leads to a good narrative) is that I am not retired.</p><p>I have practiced medicine for 36 years. I have a retired husband who would love to be able to go camping or hiking or canoeing or skiing with me when the mood hits. I have friends all over the country who I would love to see and I have never been to Yellowstone or the upper peninsula of Michigan. Not to mention I would love putting my back into battling climate change and hanging out with my twin sister. </p><p>So what would it mean to be retired? What are the issues?</p><p>1. <b>Enough money:</b> I have looked at the internet on this question and realize that it's a very individual question. As a person without a boat or a plane or children in college or expensive hobbies, I'm fine. If inflation or climate apocalypse throws a curve ball, I feel confident in my ability to downsize and still be happy. I also have some salable skills if it comes to that.</p><p>2. <b>Clearing my schedule:</b> There are some things that I have agreed to do that I need to complete. I will need to avoid committing to things that mean retirement will let people down.</p><p>3. <b>Am I really ready to quit being a doctor? </b>Here's a big one, and one reason why some doctors work forever. Possibly why interventional radiologists retire early--that's more of a job and less of an identity. (Plus they make a ton of money.) When will I let my licenses lapse? My DEA certificates? My present job takes care of malpractice--when I leave I will have only the "tail" to take care of suits that might arise during the time I worked there. But without a practice, I should need no malpractice so I guess that's ok. Will I continue to update my knowledge base, and would I even remember new knowledge without a chance to use it? Right now this seems like amputating a healthy limb. And yet...the point of retiring is to start a whole new chapter. </p><p>4. <b>How long will I be retired? </b>At what age am I planning to die? Not soon, for sure. I might have around 20 years of potentially vigorously healthy life ahead of me (knock firmly on wood) and then maybe 10 years of being very old. Is this too many years to be retired? Will I be irrelevant? Or will I slip back into the habit of being necessary and overscheduled? Will I simply slip out of the frying pan and into the fire?</p><p>5. <b>Why am I retiring?</b> Obviously I want to do all of the things that I can't do now. Wake up late, get rid of the stuff that I haven't had time to sort, sell, give away or throw away. Read those books. Write more. Learn to play more instruments. Paint the inside of the house, refinish that beautiful table with the water stains on it. Train the dog better. Just get in the car and go wherever it takes us. Teach more. Volunteer more. Work on climate change. Sew things. Make art. See old friends. Learn a few languages. Learn computer programming. To name but a few... </p><p>There are deeply unpleasant things that I would not have to ever do again. And, despite the fact that I love taking care of patients, I have ethical misgivings about the practice of medicine.</p><p>6. <b>Is it selfish to quit?</b> It cost lots of money to train me. With 36 years of practice so far, I haven't exactly squandered my training, but I am still capable and I have skills that have accrued from many years of doing what I do. So perhaps I should continue to work until I keel over in my white coat, or my osteoporotic bones are finally squashed beneath the weight of my stethoscope. Shy of that, though, maybe doing good for people in the way I have been best trained to do it is important and I should do it at least until I'm obviously losing my edge. But who will notice? There is some wisdom in leaving at the top of my game.</p><p>7. <b>Can I change my mind?</b> Doctors do come out of retirement, or so I hear. After a few years, I will still have the intuition and some of the skills I need, but I might have to take a board preparation course and re-do my medical board exams to make sure I'm up to date. There are many classic old doctor options including teaching medical students, acting as a director for a nursing home, being a hospice doctor, reviewing charts for insurance companies, consulting, becoming a member of an advisory board or a consultant. A friend of mine served on the state legislature then went back to practicing medicine very part time. Experienced doctors are in pretty high demand. </p><p>So...when shall I retire? I will continue to sit with that question. Perhaps I do not need to retire completely. Maybe a middle way exists. Or maybe I'll just retire tomorrow and stay in bed and read books.</p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com1tag:blogger.com,1999:blog-1350181109033523476.post-74999502687625932902022-04-10T16:04:00.003-07:002022-04-10T21:41:46.823-07:00I broke some ribs<p></p><div class="separator" style="clear: both; text-align: center;"><br /></div>It was a beautiful early spring day. I was working in a little patch of native plants, clearing away some pine needles and pulling dandelions. It was pretty much perfect weed picking soil, moist with spring rains but not muddy. In order to avoid stepping on the plants, I grabbed a vertical handrail support and swung myself up to the sidewalk and directly into the end of the rail. I felt and heard my rib cage crunch. Ow.<p></p><p><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkm3Mcm-nQC1KqtYFdFM7nLj8x-eKGZ0lW44GOJ-sHzn7AjAbAY2BMJSPXmykBTtrXPXoG4_olANgMhLpZbYmosy0E3-Ft0rNRnePfCHCBGYf5ROU9fYSu7vUhux0bPCf5Rwfe3_wU_2u7rRk2e83hLsD2RNlpfEZwjGOnvGms6bVLsN6fJ9faYMF7/s4032/IMG_8838.HEIC" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkm3Mcm-nQC1KqtYFdFM7nLj8x-eKGZ0lW44GOJ-sHzn7AjAbAY2BMJSPXmykBTtrXPXoG4_olANgMhLpZbYmosy0E3-Ft0rNRnePfCHCBGYf5ROU9fYSu7vUhux0bPCf5Rwfe3_wU_2u7rRk2e83hLsD2RNlpfEZwjGOnvGms6bVLsN6fJ9faYMF7/s320/IMG_8838.HEIC" width="240" /></a>When I could breathe I found that, although it was painful, I could still do some things around the yard. I was pretty sure that it would get worse, so I worked a bit and then rested inside. It did get worse. Daily it became more painful so that on day 3 almost anything I did was excruciating. Twisting, leaning over, taking a deep breath, yawning, sneezing, coughing and taking a shower. Lying down in bed was a trick. As the song goes, the rib bone's connected to the everything else bone. There was no really pain free way to lie down, though there were positions that were more horrible than others. Lying motionless on my back was tolerable, but side sleeping was out (and will be for awhile.) Repositioning uses both arms and was mostly impossible.</p><p>Anti-inflammatory drugs were a little bit helpful. I'm shy of using opiates, but a low dose of hydrocodone made it possible to fall asleep lying on my back and not be bothered by the fact that I couldn't move. Even small doses of hydrocodone instantly stop my bowels, which was actually not such a problem since all of the activities of using the toilet were agonizing. The pain relief effect of hydrocodone wears off in 6 hours or less, unlike the constipating effects, which means that trying to get out of bed was even more of a problem than getting in it. None of that rolling on your side and pushing yourself up to a sitting position since rolling was horrible and pushing with the arm on that side recruited the muscles holding the ribs in position. It's not like I couldn't do it, it's just that it hurt like stink.</p><p>I have learned later in my injury that there is some controversy about splinting rib fractures. Soon after my injury, in about 2 days I think, muscle spasms in my chest wall began to be a problem. These happen with any fracture, when muscles that are protecting the injury pull taut, jamming the broken ends of the bone together and causing more muscle spasms. Splinting (which provides traction) is the answer. I found that I was able to tie a piece of cloth around my chest, just above the injured ribs and that allowed me to breathe and move with almost no spasms. After awhile the tightly tied cloth began to hurt but that could be managed by taking it off and icing the injury and then replacing it. The controversy arises because there is concern that a splint could reduce the depth of breathing and cause pneumonia. For me, at least, it was just the opposite. Splinting allowed me to take deeper breaths. The feedback of sharp pain with each breath gave me that "can't yawn" reflex which was relieved with the cloth binding. </p><p>Breaking ribs is shockingly painful. Nothing to see from the outside, really, but wow. And it takes awhile for them to heal.</p><p>So now I have much more sympathy for people with broken ribs. But I really have no lived experience of how bad it can be.</p><p>In older people (probably older than I am, but I can't tell from the article abstract) rib fracture mortality can be around 10%. Quite a few of those are people with other injuries or who get pneumonia. Imagine. Pneumonia--your ribs hurt but then you have a fever and god forbid, a cough. Or if there is no cough you have nagging doctors and nurses insisting that you do cough and breathe deeply. And what if you have also broken an arm or a hand or a foot? My imagination goes wild. The spectrum of discomfort possible has all the colors of a bruise--the purple of agony, the green of nausea, the yellow of despair and the brown of helplessness.</p><p>How, you may ask, did I know that I had broken my ribs rather than just, say, bruised my chest wall? Did I get an x-ray? I could have gotten a chest x-ray which misses around 68% of rib fractures, or rib films specifically which supposedly miss none, but that would be painful and inconvenient, not to mention expensive (have I ever mentioned that American healthcare is too expensive?). Ultrasound, it turns out, is very sensitive for detection of rib fractures, especially if you know exactly where it hurts. I have been doing bedside ultrasound for years to evaluate rib fractures and there are drawbacks. Sometimes just touching the chest wall is nearly intolerable, so it takes practice to get it right. The sensitivity of ultrasound to detect a rib fracture is said to be around 91% compared to CT scans (which are assumed to be completely accurate but probably are not.) So I pointed my bedside ultrasound where it hurts and I found 3 rib fractures. The key findings, at least a few days after the injury, are a discontinuity in the cortex of the bone and often some edema around the injury. They are most obvious when imaged longitudinally, but a transverse view can show the cortex changing level as the transducer slides over the injury. </p><p><br /></p><div class="separator" style="clear: both; text-align: center;"><br /></div>What can be done for a rib fracture? I mentioned splinting, pain medication and anti-inflammatories, but there are also elastic chest binders with velcro closures which sound great except for the tiny problem that I can't imagine, at my worst, being able to pull open the velcro either to get it on or off. But that aside, they might be useful. Topical anti-inflammatories such as diclofenac gel sound like a great idea, but I did not notice any help at all. A lidocaine patch was initially a bit cooling but the benefit wore off really quickly after which time it just gave me a rash. K-T tape, a high tech medical tape for supporting injuries and tendinitis, is sometimes recommended but it just didn't provide enough traction. Patients in the hospital can get anesthetic agents through an epidural catheter or a nerve block, which are very effective and probably reduce the risk of death by allowing the patient to breathe and be up and around sooner. There is a condition known as flail chest, in which 3 or more ribs are broken in two or more places, resulting in an area of the chest wall that doesn't expand with breathing, rather it gets sucked in, making it harder to fill the lungs. For this kind of injury as well as very displaced fractures, orthopedic surgeons can actually place stabilizing hardware in the ribs, screwing plates over the fractures. Sounds painful. <p></p><p>For me, the most useful procedure, outside of my tightly tied sarong, my anti-inflammatories and ice packs, was acupuncture. I had two acupuncture treatments in the acute period, in the week after my injury, and they seemed to really relieve pain and speed my healing. </p><p></p>How long, then, is the healing phase? I expect to be mostly healed within a month of my injury, because this is getting really old. I read that it can take 3 months, but that's ridiculous and if it takes that long I will start writing letters to whoever's in charge. <p></p><br /><p><br /></p><p><br /></p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com3tag:blogger.com,1999:blog-1350181109033523476.post-72842851388255147212022-01-03T10:20:00.002-08:002022-01-03T10:20:50.914-08:00Poem for the New Year<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEj-BOJ9v97nGkeIlvPW20GLIBXByikw5o3mIrkxV6ZXL9vffur1WK3BoYyG5KUjPFoHkn6XGK9HlFotNQdGLhwnRKhf1lyDgwvNcbCLqXu0903lM_jlMp46S5vbZW9JqMw041Aem62b_VDJTzUR_sYQ6CypwtOJ9X-lUEznTqpRYZHvLZLBoQQhwCS4=s4032" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/a/AVvXsEj-BOJ9v97nGkeIlvPW20GLIBXByikw5o3mIrkxV6ZXL9vffur1WK3BoYyG5KUjPFoHkn6XGK9HlFotNQdGLhwnRKhf1lyDgwvNcbCLqXu0903lM_jlMp46S5vbZW9JqMw041Aem62b_VDJTzUR_sYQ6CypwtOJ9X-lUEznTqpRYZHvLZLBoQQhwCS4=w240-h320" width="240" /></a></div>Happy 2022--let it be filled with good things.<p></p><p>And on that note, I wrote a poem. (After reading Manifesto of Encouragement by Danielle LaPorte)</p><p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Even now</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;"> </span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">All is not lost--</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">even now</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">your frozen pipes are melting.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Cells in your body are repairing what is broken and injured.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">T cells and B cells are working together to keep the
bacteria and viruses in balance with the cells that make up what you think of
as you.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Macrophages are cleaning up the mess. Thanks for your
service.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">That cancer cell? Nope. Sorry buster, not today. Natural
killer cells. You don’t even pay them.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Certain very bad jokes aren’t being told. The last person to
tell them has just died. He didn’t use the internet so the ripples of their
passage only exist in the vibrations of rocks.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">That thing you did that still makes you cringe? Even now the
last person, other than you, who knew about it has just forgotten.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Just yesterday you learned a new thing and at this very
moment you remembered what it was.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">People who feel that power and wealth are their birthright
are aging. Their telomeres are shortening. Not a thing they can do about it.
Their children are consuming post apocalyptic fiction in which the brave and
the generous survive and communities work together to create a more equitable
and exciting world. They are forever changed.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Under the warming Greenland ice sheet, little live things
are evolving to take up a niche not before available to them.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">The Bay Area is introducing city wide composting to reduce
methane pollution from landfills.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">A mother Grizzly bear is sleeping and her baby is growing
inside her, ready to emerge when it is warm enough.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Ladybugs are hunkering, their shiny red bodies gathered
together against the cold, their very slow biological processes preparing for
spring.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Somewhere in space forms of life are solving problems we
didn’t even know existed.</span></p>
<p class="MsoNormal" style="line-height: 107%; margin: 0in;"><span style="font-family: times;">Somewhere far underground things are happening that are just
as complex and mind blowing as what’s going on at the surface and we have no concept
of what they are. But they are immensely fascinating.</span></p>
<p><span style="font-family: times;">In the places in between, that we physiologically can’t
imagine because three dimensions are all we have, an awareness exists in which
all of this is good. </span></p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-72842717934640766962021-12-05T12:00:00.000-08:002021-12-05T12:00:10.310-08:00An opinion--Love your neighbor<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjc_o8qEJioVMfS_ZPiV1zTWHmDsyWSj96ta3CeUClR58u7nNUX8Z7TUxLinJmcqytMpTwfnX5UFoPMLySQu5C-VlaiHktRPn7J6QR4qYfzam_CObbXQLd-Efth8_kfr3Wn1Os4z5KGYkU/s4032/IMG_7815.HEIC" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="3024" data-original-width="4032" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjc_o8qEJioVMfS_ZPiV1zTWHmDsyWSj96ta3CeUClR58u7nNUX8Z7TUxLinJmcqytMpTwfnX5UFoPMLySQu5C-VlaiHktRPn7J6QR4qYfzam_CObbXQLd-Efth8_kfr3Wn1Os4z5KGYkU/s320/IMG_7815.HEIC" width="320" /></a></div>I've noticed that when I'm at work, I generally love my patients. I may have complaints about them, wish they would behave differently, get frustrated with their choices, but I do feel a warm connection with them. (OK, there are people/patients who I find I am violently allergic to, but they are rare.) I work in an area which votes differently than I do, and I don't necessarily agree with my patients, but I have their backs and want what's best for them. <p></p><p>I don't necessarily feel that way about my fellow Americans. As a group many of them seem to act in ignorant, short sighted and often hateful ways. But when I meet them in a stuffy little office, I like them and on the important stuff, we usually see eye to eye. Why is that?</p><p>I think I'm being hacked. My brain, that is. I think that there may be a concerted effort going on to make me feel like I'm not a powerful and loving part of a valued whole. It seems like what I read and what I'm exposed to in news and what passes for news makes me feel like I am, instead, part of a small enclave of right minded people struggling for a way of life. And it isn't infrequent that I read something that makes me realize that, even within that group of people who I feel are my friends, who really understand what I understand, there are people who are real jerks and are working to steer my right minded community in the wrong direction. So almost daily it seems like the group of folks who are "my people" is getting smaller.</p><p>This mindset makes me chronically grouchy and suspicious of others. I may like a painting, for instance, but what if the painter is an ignorant SOB? How about that cool quotation I just heard--would the philosopher who wrote it agree with me on other subjects?</p><p>I fear that this ever smaller division of people into angry activists for different causes will not serve us well when inevitable disasters occur. Anyone who has been reading this blog understands that I am expecting more climate disasters, but just recently we have been dealing with a worldwide pandemic which is only peripherally connected to climate change. Big events seem to be happening more often lately, and we will do better with them if we are ready. Ready, how? Ready by loving one another so we can work together when we need to. </p><p>I just saw a movie called Finch, one of many post-apocalyptic stories available for consumption. It takes place in a world devastated by a solar flare, but mostly by a dysfunctional human response to a solar flare. (Solar flares could happen, actually, and will fry our electrical system and most of our mass communications, among other things. They are random, happening all the time, but the sun has to aim one exactly in our direction to hit us properly--I digress.) We need to feel compassion for each other (and have back up systems for predictable disasters, of course) in order to find our way out of trouble.</p><p>I don't think I'm being hacked by someone who wants the world to fail spectacularly. It is way more likely that this hacking is part of our "click on what makes you mad" internet, but that it is magnified by groups that know they can manipulate us if we splinter into squabbling sub factions. This may include national governments that want us to vote in ways that do not represent our best interests, but may also benefit corporations that would like to sell us more things we don't need. It is a helpful short term strategy for making a population impotent and biddable, but it is going to hurt all of us in the end.</p><p>Lately I've been thinking about divisive subjects and how I can have compassion and share common goals with people who disagree with me. Here are a few:</p><p>1. Abortion and the right of a woman to choose to end a pregnancy: I've been looking at the laws that stem from Roe v. Wade. I believe that women should be able to end an unwanted pregnancy, but I don't believe that it is meaningless to do so. In the US, we have laws that allow a pregnancy to be terminated at or before 24 weeks. It is no small thing to get rid of a small, helpless proto-human that looks like a tiny baby, even if it is not viable outside of the womb. People feel very strongly about this, and I see why some would vote entirely for people who are opposed to abortion, without being anti-woman. This is a subject upon which kind and reasonable people can disagree. It is also a subject where strong emotions can make people do terrible things and say terrible things about each other. Emotions get high on the pro choice side because many women who have unwanted pregnancies are young and quite a bit of sex in this population is coerced or not consensual. Even pregnancy as a result of consensual sex has a huge price in terms of limiting life options for the woman but not usually the man. Women desperate to end a pregnancy have been historically subjected to pain, suffering and death when obtaining illegal abortion. Freely available short and long term birth control as well as morning after pills can help reduce the problem but there will always be unwanted pregnancy. Controversy will not cease and respect for each others' point of view will be hard but not impossible to maintain.</p><p>2. Immigration: I believe that we should be open to immigration of people who want to be in the US and whose homes have become unlivable for them. But I also see that the principles I hold dear, of diversity and inclusion, can clash with globalization. Countries have developed cultures over centuries that are different from one another and this is valuable. Inclusion, for me, means inviting people in to a place, a country that I feel is home, but not giving up that home or letting it change so it is unrecognizable. I think we can be both welcoming and inclusive without giving up who we are, that the cultures people bring in will enrich us, but I can see how reasonable, non-hateful people might resist mass population movement. (Those reasonable people may want to look at preventing and mitigating climate change to avoid such mass migration.)</p><p>3. Vaccination and masking: I believe that people should protect each other, and in particular people who are vulnerable to severe illness and death from Covid by getting vaccinated and masking in situations where there is likely to be active Covid infection (moderate to large groups of people, some of whom may be unvaccinated.) But I understand that for some people, wearing a mask is more difficult than it is for me. I live in a place that is not hot and humid and do not have problems with being overweight or experiencing asthma or acne. Also many people are dependent on seeing facial expression to communicate. Mask use isn't easy. Vaccination is safe but it is not without risk. Studies show that there are no statistically significant increases in severe reactions such as blood clots or neurological complications with Covid vaccination, but some people do get problems out of the blue after a vaccination which are probably vaccine related. Like some of my vaccine hesitant patients, I don't like being told what to do and I don't necessarily trust drug companies, medical experts or the federal government to keep me safe. I also think that we don't hear enough about how protective natural infection is and that vaccine makers have a financial interest in making us believe that vaccines are the only way to be safe from Covid infection. I'm willing to do exactly as the CDC says in this situation, since this is a terrible worldwide pandemic, but I don't want to make this submission behavior a habit. Some peoples' jobs and ways of life were ended with Covid restrictions and they feel angry at the powerful decision makers who forced this on them. This is a real grievance and leads people to resent those they feel are responsible or complicit. As a person who works in healthcare, I also have strong feelings as I see colleagues burning out taking care of people whose infections could have been prevented by responsible behavior and I feel grief for people who die or are disabled because we, as a country, couldn't follow some pretty simple recommendations. But I can hold those feelings and also keep people who disagree in my heart.</p><p>The second commandment in the Judeo-Christian bible says "love your neighbor." Each of the ten commandments is difficult for people at times which is why they survive and are meaningful. It can be hard to love your neighbor. It can also be really easy in most cases, if we work at it and see it as necessary. There are jerks, too, so I'm not going to be absolutist about it, but there aren't nearly as many ignorant and unlovable people as we are lead to believe. We need to start broadening our concept of "us" so we can work together now to take care of the world and each other.</p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com1tag:blogger.com,1999:blog-1350181109033523476.post-86631672094823032502021-11-22T15:24:00.003-08:002021-11-22T21:44:33.546-08:00A little view of the climate and the other blog! And yay, Covid drugs!<p> </p><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgprtT-2deB6h9XL9uP_yE20JaykWBuMixGxZapQpNdP3jOiBsEgs2Hh-2BQHQYcFi1iuzPrQ-E2UbEbIueaCe7hQ09lRuLzvOLg5x0gdse5WKT1sn8ysJ6BVI8Do6hQX6nZvIzOAnpmz0/s2048/IMG_7455.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgprtT-2deB6h9XL9uP_yE20JaykWBuMixGxZapQpNdP3jOiBsEgs2Hh-2BQHQYcFi1iuzPrQ-E2UbEbIueaCe7hQ09lRuLzvOLg5x0gdse5WKT1sn8ysJ6BVI8Do6hQX6nZvIzOAnpmz0/s320/IMG_7455.jpg" width="240" /></a>I've been writing a few things about the climate at the other place, https://doctorjanicesblog.org/. Just thought I'd mirror those here. Since I last mentioned the climate in this blog, there have been catastrophic floods in the Northwest and record high temperatures in the east coast. The area of South Sudan where I have spent time teaching ultrasound and helping out a bit in a hospital serving internally displaced people remains flooded. For most of a year now there have been no safe places to sleep in the land near Old Fangak, other than those protected by mud dikes and sandbags. So not safe, actually, at all. Gardens are flooded. Roads are rivers. I see photos and I don't recognize the place. I can only barely imagine what it must be like to be trying to live there. Flooding is normal in the rainy season, but never persisting through the dry season like this. The climate continues to change and the results are unpredictable and often tragic. I have been writing a bit about it.</div><p></p><p><a href="https://doctorjanicesblog.org/f/a-climate-bank-how-would-that-work" target="_blank">1.</a> This first one is about a climate bank, part of a bill in Congress, who knows whether it will pan out, but the concept is definitely great.</p><p><a href="https://doctorjanicesblog.org/f/a-price-on-carbon" target="_blank">2.</a> The next one is about Carbon Fee and Dividend, the basis of proposed legislation, in which taxing carbon pollution uses the free market system to encourage switching to renewable energy.</p><p><a href="https://doctorjanicesblog.org/f/methane-might-just-roast-the-planet" target="_blank">3.</a> This one is about methane, and why we need to limit its release into the atmosphere. Methane sounds innocuous when we call it "natural gas." Kind of like "natural food" except not.</p><p><a href="https://doctorjanicesblog.org/f/the-forest-act" target="_blank">4.</a> Today's offering, about the FOREST act which has a chance of passing in congress since it has bipartisan support. It fights worldwide deforestation.</p><p>On the subject of medicine, I'm very excited about the introduction of two antiviral medications for Covid. Molnupiravir (named after the hammer of Thor, initially intended for influenza) inhibits a polymerase enzyme to create destructive mutations in coronavirus. Paxlovid combines a protease inhibitor, ritonavir, originally use in the treatment of HIV and another protease inhibitor more specific for Covid 19. This combination drug helps limit the viruses ability to replicate itself. Having effective drugs, especially ones that may be synergistically effective if combined, gives me hope. The fact that the government has been subsidizing medication related to Covid makes me believe that their newness may not price most people out of the market. New drugs are usually unaffordable, but the need to make these globally available may mean that they do not go through the usual multi-year period in which nobody without gold plated health insurance can afford them. Vaccination helps prevent infection and severe disease but we also need medication to treat infections that break through our immunity.</p><p><br /></p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-23142988401676581092021-10-17T20:04:00.004-07:002021-10-17T20:04:52.467-07:00Why I haven't been writing much: climate change<p>What I do most and what I do best is medicine. Healthcare. So I began to write (this blog was created in 2009) as I saw the compassionate practice of medicine being threatened by a system that has perverse incentives, causing it to be crazily expensive and ever more inadequate. </p><p>There was a great deal of debate surrounding equitable payment for medical care leading up to passage of the affordable care act. Much of the debate was uninformed, so I wrote things, from the point of view of a real doctor working with real patients in a variety of pretty normal places. I added some data to the roiling pot of data that is the internet. Threw virtual messages in bottles into the virtual ocean. There are 353 posts, around 2700 visits per month, a few more than 624,000 views over the life of the blog. Maybe some of those views influenced people in ways that made medicine more compassionate, more nuanced, equitable, effective and less ignorant, expensive and daft.</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8a2wgVL7Twj0LP-L6eHDb8mEDps4ZniEg-xl8IqbKrh5vu2nBkLdKgyfSptea7WeLB3Wj89oPj-4a5zb6r3nErBWT96H35_k_f3K_1z0-sdAEy-RC1akJu2GYI1CsytXrf0yY8zZ-6XU/s2048/IMG_4480.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8a2wgVL7Twj0LP-L6eHDb8mEDps4ZniEg-xl8IqbKrh5vu2nBkLdKgyfSptea7WeLB3Wj89oPj-4a5zb6r3nErBWT96H35_k_f3K_1z0-sdAEy-RC1akJu2GYI1CsytXrf0yY8zZ-6XU/s320/IMG_4480.jpg" width="240" /></a></div>When Covid hit, there was so much misinformation and the good information was so difficult to access that I wrote lots of posts. Ten in March 2020 alone. Eventually the information people could find got better, even the CDC was producing easily accessible information so I didn't write so much. I had more time for all of those other things we did during Covid social distancing! <p></p><p>My husband has been working on climate change with an organization called <a href="https://citizensclimatelobby.org/" target="_blank">Citizen's Climate Lobby</a>. It is a volunteer organization that pushes for legislation to enact a fee on carbon pollution. He has been actively worried about the effects of greenhouse gases on global climate for decades, but has been involved in this organization for only a few years. It is a good organization doing good work. I have been in my own medical bubble until it just recently popped due to reading <u><a href="https://www.theguardian.com/books/2020/nov/20/the-ministry-for-the-future-by-kim-stanley-robinson-review-how-to-solve-the-climate-crisis" target="_blank">Ministry for the Future</a></u> by Kim Stanley Robinson and experiencing the <a href="https://en.wikipedia.org/wiki/2021_Western_North_America_heat_wave">2021 western heat wave</a>. In late June and early July we were trapped inside our stifling houses due to unprecedented temperatures that were followed by wildfires, due most likely to climate change. <u>Ministry</u> is a work of fiction that reads like a near future history book, detailing how the human race manages, by hard work and creativity, to barely survive the global increase in temperature that is definitely going to take place. It is optimistic, because it is not necessarily true that the human race will pull together to do what is necessary to save what we love and value, but also motivating. It woke me up to the fact that we are in an "all hands on deck" situation.</p><p>But it was just a novel.</p><p>Then came the heat wave. I work with people who are poor, who live in trailers or houses without air conditioning, or who have so little money that running an air conditioner even if they have one is too expensive. They live in parts of town where there is no shade. They are dependent on equipment to move around, like wheelchairs or walkers, making it hard to get to a cooler place. They use oxygen which requires electricity to function and there were blackouts. Some are drug addicted and homeless. Some of them died. All of them suffered. It was horrible. It was horrible for them, but also for me. I was grateful I worked in a place with reliable air conditioning and that my car had air conditioning that actually worked. Even with that, it felt like the planet where we live was no longer friendly to humans.</p><p>Since that heat wave, I have seen ripple effects. Crops failed. Trees appear to be dying. There are a shocking number of dead deer in the woods. Looking back, last summer wasn't a fluke, it's a trend. </p><p>Healthcare is still really interesting. I find certain trends to be heartening--there is more telemedicine increasing access to care, there is more focus on treating drug addiction because of the epidemic of overdose death. Other trends are disturbing--politicization of health decisions, hostility to healthcare workers. Lots to write about. But what really gets under my skin right now is a larger system that is malfunctioning and a more pressing set of problems that need action right now. The impact of climate change on peoples' health is going to dwarf anything I might be able to do to improve medical care.</p><p>This blog will still be primarily about healthcare, best to be consistent. But I will also be writing about other things on <a href="https://doctorjanicesblog.org/">https://doctorjanicesblog.org</a>. I initially got that URL because it is really hard to be directed to whyisamericanhealthcaresoexpensive. But it is also a comfortable home for other writing. So there you go. The reader is welcome at either location to read and participate.</p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com2tag:blogger.com,1999:blog-1350181109033523476.post-45028262756277673782021-09-06T19:30:00.000-07:002021-09-06T19:30:02.886-07:00Ivermectin for Covid--Does it work? We don't know.<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdfJUBz1ISsY4HV26BR6XY1Q8bsidpTr3w6cJYwozrxgVkc_li5mbVQbk8bq3ww1DTKI14gi_s8GPz74JITGVk3CgG-wOr08FI1Hiskf4i-QwM4q9ATTSl9OP8bXVlNDNj7RFKiaw4HlE/s4032/IMG_6883.HEIC" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdfJUBz1ISsY4HV26BR6XY1Q8bsidpTr3w6cJYwozrxgVkc_li5mbVQbk8bq3ww1DTKI14gi_s8GPz74JITGVk3CgG-wOr08FI1Hiskf4i-QwM4q9ATTSl9OP8bXVlNDNj7RFKiaw4HlE/s320/IMG_6883.HEIC" width="240" /></a></div><br />Lately there has been quite a heated controversy about whether to use ivermectin for Covid-19. The <a href="https://www.fda.gov/consumers/consumer-updates/why-you-should-not-use-ivermectin-treat-or-prevent-covid-19">FDA</a>, a US federal agency responsible for providing unbiased information to protect people from harmful drugs, foods, even tobacco products, has said that there is not good evidence of ivermectin's safety and effectiveness in treating Covid 19, and that just about sums up what we truly know about ivermectin in the context of Covid. The CDC, Centers for Disease Control, a branch of the department of Health and Human Services, tasked with preventing and treating disease and injury, also recently warned people not to use ivermectin to treat Covid outside of actual clinical trials.<p></p><p>Certain highly qualified physicians, including ones who practice critical care medicine and manage many patients with severe Covid infections in the intensive care unit vocally support the use of ivermectin to treat Covid and have published dosing schedules and reviews of the literature supporting it for treatment of early infection, also to prevent infection and to treat "long Covid" which is the distressing aftermath of infection. </p><p>Many articles have come out, in medical journals, also in highly regarded popular sources such as the NY Times and Wall Street Journal, primarily either discouraging the use of ivermectin for Covid 19 or deriding people who would prescribe or seek out such treatment.</p><p>What is going on?</p><p>Ivermectin is one of several antiparasitic medications derived from a soil bacterium which have been game changing for treating both animals and people. William Campbell and Satoshi Omura won the Nobel Prize in 2015 for developing the parent drug, Avermectin, from which ivermectin was derived. Ivermectin shows promise in eliminating two horrendous tropical diseases, River Blindness and Lymphatic Filariasis (previously known as elephantiasis due to the disfiguring swelling it causes.) As it has gotten more available and less expensive, it has become one of my go-to medications for severe cases of scabies, a tiny mite that lives on the skin and causes itching and often bacterial infection. It works extremely well. Ivermectin, in doses used to treat parasitic diseases, is very safe and low in side effects. So in this mystery of why ivermectin has become such a controversial subject, we have two main questions. <b>What </b><b>is our evidence that it works and what </b><b>is the harm of using it?</b></p><p><b>The Evidence that it Works: </b>It is very easy to convince ourselves that a drug works when it does not, if we don't do really good studies. There have been many drugs that have appeared to work for Covid which have not actually helped or, indeed, were shown to cause harm when we gathered enough high quality data. There are many sources of bias that can lead to this sort of thing. Let's take, for example, chocolate ice cream. Say we have a community that is ravaged by Covid and we introduce chocolate ice cream therapy. We may find that patients who eat chocolate ice cream do, in fact, recover from Covid faster than ones who do not. It could be the ice cream or it could be the fact that people who want to eat ice cream are starting to feel better or that we are just getting better at treating Covid by the time we start our chocolate ice cream study. It could be related to other characteristics of patients who like chocolate ice cream. Lactose intolerance is more common in people of color who have also been noted to have higher mortality rates from Covid. Biases can enter into studies in very subtle ways or in ways that are not subtle at all. Ivermectin can kill Covid viruses in the laboratory, but so can other drugs which have proved not to be effective. Whole areas of the world have started to use ivermectin as a treatment for Covid, primarily in the developing world. Physicians who back ivermectin as treatment note that in those communities after ivermectin is introduced, death rates start to fall. But we have all noticed that when Covid death rates get really high, they eventually start to fall anyway. It's the nature of the disease and the nature of people, who use many mitigating strategies when the epidemic heats up, including things like masking and lock downs.</p><p><b>What is the harm?</b></p><p>I have mentioned that ivermectin is pretty safe. It is, at standard doses. The most responsible of the doctors who recommend ivermectin recommend pretty standard doses, but ivermectin is available in veterinary formulations and is really inexpensive, so people are just buying it online or from local feed stores and taking it. When they take it in veterinary doses, and many will because there are no instructions for human use, they can be poisoned. I just looked online for "horse paste"--one veterinary option, and found that a little tube of horse dewormer weighing a small fraction of an ounce, had 10 standard human doses in it. It is not obvious to a regular person that a tube is too much and next to impossible to figure out how to squeeze out a tenth of a tube for each dose. Plus it was very unclear what the other ingredients in the paste were, since only about 1/50th of it was ivermectin. </p><p>So why don't we just prescribe human ivermectin in safe doses to all of our patients who might request it, or if we believe the very low quality data available so far, to all patients who have or might have Covid? It would certainly be safer. The reason is that doctors are supposed to be prescribing medicine based on good evidence that it works. So far we do not have good evidence that ivermectin works.</p><p>Another harm is in the overly enthusiastic promotion of ivermectin by these respectable doctors, describing patients who say that it saved their lives, making people think that they don't really need to get vaccinated, because there is always ivermectin which will cure them. Vaccination definitely can prevent Covid infection and reduce its severity in vaccinated patients who are infected. This is supported by really good unbiased studies. Encouraging patients to believe that they can safely forgo vaccination will prolong the pandemic. The experts who believe in ivermectin's effectiveness also imply that the CDC and FDA and doctors who trust them are either lying or dimwitted which is very misleading and can cause patients to mistrust their doctors or doctors to mistrust each other. That bad feeling is made worse by the other side when they call ivermectin a "horse dewormer" which, though partially true, obscures the fact that it is safe and effective for several human diseases.</p><p>But does ivermectin work to treat or prevent Covid 19? We don't know. Studies done so far have been plagued by biases (see this Cochrane Collaboration <a href="https://www.cochrane.org/CD015017/HAEMATOL_ivermectin-preventing-and-treating-covid-19">article</a>, summarizing the data.)There are good studies in process right now. The placebo effect is powerful, and though I love a good placebo, it slows progress toward effective therapies if people are sure that they have a useful drug already. Ivermectin may prove to be helpful in treating Covid, but we really don't know yet and the road to a Covid cure is already littered with drugs we thought worked but did not.</p><p> </p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com1tag:blogger.com,1999:blog-1350181109033523476.post-45017239777584588172021-05-08T15:25:00.000-07:002021-05-08T15:25:38.712-07:00Racism, structural Racism and a wonderful speaker, Dr. Kimberly Manning<p></p><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtoKOnyASBzbG71fiI-ZH97xMrz2EgtpVV1LDzLAidSvCkU0nRVCHS5jTWdczDA_j2KGONlababqFKgcFtvvwu3WiOeXqhqMFfUbWB98PrF5l3wumNsZXqWEtNzjDQMnHjKvXkm1gLOto/s2048/IMG_6123.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtoKOnyASBzbG71fiI-ZH97xMrz2EgtpVV1LDzLAidSvCkU0nRVCHS5jTWdczDA_j2KGONlababqFKgcFtvvwu3WiOeXqhqMFfUbWB98PrF5l3wumNsZXqWEtNzjDQMnHjKvXkm1gLOto/s320/IMG_6123.jpg" /></a></div>I just heard a talk by Kimberly Manning MD, <span style="font-family: inherit;"><span style="background-color: white; color: #494949;">Associate Professor of Medicine as well as the Associate Vice Chair of Diversity, Equity, and Inclusion at</span> </span>Emory University School of Medicine, department of Medicine at the American College of Physician's virtual yearly meeting. She gave one of the plenary addresses and hers was called "Broadening your life lens, the case for diversity." I almost didn't watch it because I attend this meeting for the concentrated information on how to take care of patients with certain conditions that I get from talks with names like "Pearls for the management of insomnia not to miss." I thought that this was a talk for other people, and since I had studied this subject, maybe not for me. But I watched it anyway. It was great. <p></p><p>Dr. Manning is a full professor at her institution, which makes her very special. She told us that 0.7% full professors of medicine are black women. 25% of full professors are women and Black women make up about 8% of our population. There is just no statistical justification that I can see for this dismal representation. When I was in training, over 30 years ago, at Johns Hopkins University School of Medicine, centered in Baltimore in a part of town which was overwhelmingly Black, I had no physician teachers who were Black and I can only remember 2 who were women. That seemed normal at the time.</p><p>"Every system is perfectly designed to get the results it gets." she quoted (the internet attributes this to <a href="https://en.wikipedia.org/wiki/W._Edwards_Deming" target="_blank">W. Edwards Deming,</a> a statistician and engineer who wrote about changing systems and famously about the lenses we should use to see the world in order to improve results. He was an important part of the revolution in manufacturing in Japan that lead to them becoming famous for innovation and high quality, but I digress.)</p><p>Our system is racist. Systemic racism means the system is racist, which it is, looking at outcomes. The average black family has $8600 in savings, the average white family has $51,400 per <a href="https://www.businessinsider.com/personal-finance/average-american-savings?op=1#average-american-savings-balance-by-race" target="_blank">Business Insider</a>. Black unemployment during Covid is 5.4% higher than white unemployment. 40% of prison inmates are Black though only a bit less than 14% of the US population is Black. </p><p>Everyone who is part of the system who isn't actively working to change it is racist, not meaning that they have any particular beliefs but that their involvement in the system that is racist is complicit (Dr. Manning didn't say this, perhaps she was being gentle, perhaps she has a better way of approaching this issue. That's just how I parse it.) </p><p>Some people who are white feel really uncomfortable with the term and would like to drop it, or explain that they are not racist. That's not useful. White people have generally benefitted in terms of economic and social advantages and it is useful to take responsibility for that and work to change things. It is not necessary to point out that it was our dead relatives that directly participated in slavery or enforced Jim Crow laws, or even that they were among the white people who thought that slavery was bad. At this point, if you are white, you reap benefits not available to people of color. If you are my age, you may think about how we felt about white people participating in the apartheid system in S. Africa. As I recall we did not cut white South Africans a break. Also the American south. I recall not having much sympathy for white southerners living in a system that had race separating policies if they weren't actively working to change those. History will probably judge white people like me badly.</p><p>People may say that we did fix that, we changed policies after the civil war and now laws don't uphold overt preference for white people. Those laws relating to race were a start and outcomes that are unequal require that we keep working. There is a lot of history, going back to the transatlantic slave trade, and it's going to take ongoing work to move away from racism. Racism is tied up with many other social and economic inequalities, very tricky and very embedded in our day to day reality.</p><p>We are in an ongoing situation of wealth disparity, climate catastrophe, lack of opportunity for women. Add your own. Picture yourself in the future, reading a history of our present. Was there something you could have done that you would wish you had done?</p><p>I realize that in writing about this subject, I am presuming that I know more than other people and deserve to be heard. Traditionally that has been the privilege of being white in America. It is an important practice for me to work on, to hush and let others talk. In the spirit of that, here is Dr. Kimberly Manning speaking about diversity and inclusion in her experience in Medicine: <a href="https://www.youtube.com/watch?v=YsfvDAeMqdI">https://www.youtube.com/watch?v=YsfvDAeMqdI</a></p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-28601962313614941222021-04-11T21:39:00.001-07:002021-04-12T17:51:48.458-07:00Covid, re-evaluated one year later.<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5iK7iQAE8tkWHEJSH86PhSXe2Am0CVXqOx1WfV_OCKJifpobb8kU-VgRzeIXiShybx85y6c2xpS4NuRB6rhqKZlTA6qcDkoZXye-8Jr6W34OlwEePfEE8etMt7MWWoTUkLGLJYtPYRQU/s2048/IMG_5934.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="435" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5iK7iQAE8tkWHEJSH86PhSXe2Am0CVXqOx1WfV_OCKJifpobb8kU-VgRzeIXiShybx85y6c2xpS4NuRB6rhqKZlTA6qcDkoZXye-8Jr6W34OlwEePfEE8etMt7MWWoTUkLGLJYtPYRQU/w326-h435/IMG_5934.jpg" width="326" /></a></div>In early March 2020 I began to write posts about Covid 19. There were few places that people could get good information that addressed the big picture and made it possible to understand what was happening. It seemed like I should write some things that made sense of it all. I wanted to write about what I knew, or thought I knew was true, since there was so much misinformation circulating. So, during the second half of March, I wrote nine blog posts. <b>What did I say and was it true?</b><p></p><p>In my very <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/covid-19-how-novel-coronavirus-will.html" target="_blank">first</a> post I talked about how <b>everything would change</b>. How we would burn less carbon, we would learn how not to travel for work, how we would learn not to transmit other viruses, like influenza. <b>That was all true</b>. The demand for gasoline was so low that oil prices dropped to a fraction of the cost of production. Planes didn't fly much. We haven't had a flu season to speak about due to infection control measures. I said we should have massively <b>expanded testing</b> because it would allow people to get back to work, which <b>would have been nice</b>. Also that people would probably be contagious for about 2 weeks after they were infected, which was close to true. I thought that hospitals would get more efficient and people would become kinder to each other. I'm not sure that happened.</p><p>The <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/we-all-have-covid-19-mycoviddiary.html" target="_blank">second</a> post said that <b>we should forgive ourselves for not knowing what to do about the pandemic</b> because we had not been through one before. And that we should wear supportive shoes while dancing around the house due to the risk of developing plantar fasciitis from exercising in our houses barefoot. And that the eventual tragedy that would come of this would be hard to predict. Turns out I developed a different overuse injury from exercising around the house, but other than that, the blog wasn't far off.</p><p>In my <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/covid-19-my-covid-day-mycoviddiary.html" target="_blank">third</a> post I suggested that <b>we would use fewer resources</b> by not traveling or going out and that would mean that we might have more downtime and not have to be as productive which could be good. Indeed people were less productive (and some felt bad about that) and used fewer resources and learned to cook and make music and dance and things. But some also lost their businesses and became homeless. We seem poised to become just as frenetic about spending and achieving and traveling as soon as vaccination/herd immunity makes it safe. <b>We shall see how our consumption resets itself</b>.</p><p>The <a href="fourth blog" target="_blank">fourth</a> post mentioned that the <b>direct stimulus payments proposed in congress would mean a lot to my patients. They did.</b> Stimulus payments were a kind of experiment with the concept of a guaranteed basic income. They were a way to distribute money from the wealthy to the grindingly poor in a way that would be immediately helpful. In the end it wasn't enough money, and the poor didn't get their stimulus checks quickly enough to keep them from harm, but it was good as far as it went. I couldn't have predicted just how well the wealthy would do, with the stock market recovery. So even with stimulus checks, it seems like the wealth gap between rich and poor has widened.</p><p>The <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/covid-19-why-does-it-seem-like-nothing.html" target="_blank">fifth</a> post looked at<b> exponential growth</b>. I suggested that we weren't seeing much Covid in many parts of the US because we were on the skinny end of a growth curve which would mean that numbers of sick people would appear to increase slowly until there were suddenly many people affected. This was still a foreign concept for most Americans in March 2020. I also suggested that if we did everything right (at that time it was primarily hand washing and social distancing) we could avoid the huge numbers of cases and deaths that were predicted. Our little Idaho community did avoid big numbers by some pretty serious lockdowns. Brutal exponential growth curves nailed many cities and towns. I predicted, though, that the whole epidemic might last 3 months. I hadn't thought about the second and third waves, which have pushed our troubles out beyond a year now. Despite looking at data from the influenza epidemic of 1918 and 1919 in which there were multiple waves, <b>a pandemic that lasted over a year was beyond my imagining</b>. </p><p>My <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/ppe-personal-protective-equipment-how.html">sixth</a> post talked about PPE, how it's used and what it's good for. It wasn't far off, as far as I can tell. At the end <b>I said that making cloth masks would be of limited usefulness. Not true</b>. We ended up making some pretty good ones, and now adequate cloth masks are pretty easily available. Many cloth masks are ill fitting and uncomfortable and people wear them below their noses, or so loose that they are probably minimally effective. Probably nobody will know what benefit an ill fitting haphazardly worn cloth mask provides but I'm right now going to give it a thumbs up over no mask at all. Surgical masks, N95 and KN95 masks are still better. </p><p>The <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/ppe-personal-protective-equipment-how.html">seventh</a> post had a lot of data which I wasn't at all sure was going to end up being true. Most of it was true. It was <b>stuff about incubation periods, transmission and catching the virus from people who are asymptomatic</b>. Scientists were publishing good data, even a year ago. With one exception: it seems, now, though, that there is very little risk from viruses surviving on surfaces, which is great, because I didn't like wiping down everything with nasty anti-viral chemicals or leaving my groceries out for days while the viruses died.</p><p>Post <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/sex-in-time-of-covid-19.html" target="_blank">number eight</a> was about <b>sex</b>: whether it is safe during the time of Covid. If sex is defined as in-person messy kissing etc. with one or more casual contacts, the answer was that it was <b>not safe</b>. I linked to a New York public health document that was perfectly explicit. It was all true. <b>Sorry, dating in the time of Covid is super risky</b>.</p><p>The final March blog post, <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/covid-19-and-death-rates-doctors-know.html" target="_blank">number 9</a>, was about <b>death rates</b>. On March 27 the official number of deaths from Covid in the US was a mere 994. I said that this was unlikely to be the actual number of people who had died from the disease because it takes a long time for a Covid death to be correctly counted. I explained why. That turned out to be right too. Imagine that day, in March, when <b>Covid had killed just shy of 1000 people</b>. Now we have lost over 1 in 600 people to the disease. Which is probably still an underestimate.</p><p>So overall, it was pretty good information. I've stopped writing about Covid, mostly, because there are now excellent sources of information and much less misinformation going around. Most of us have figured out how to inform ourselves accurately. Many search engines make it more difficult to spread false rumors (though there are still pretty persistent pockets of wrong information surrounding vaccines among other things, easily available on the internet.) In our year of living online, many well informed people have done a beautiful job of writing about the novel coronavirus. This leaves me more time to train my puppy and dance around the kitchen like other people do in the time of Covid. </p><p>Since March 2020 we have experienced a whole year of a pandemic, something that nobody younger than 100 has been through. We have seen a vaccine produced, tested, introduced and delivered in less time than anyone thought would be possible. It became clear to anyone paying attention that having a president who tried to hide the dangers of a deadly and novel infectious disease in order to maintain consumer spending and corporate health had devastating consequences. Who would have guessed the executive branch of government would be so important? Wearing face masks in public has become normal and has prevented a vast amount of viral illness related and unrelated to Covid. I would not have placed money on that particular horse. Most of us have gone a year without going to a gym or dining inside. Seriously? Yes, indeed. That happened. We have made many inconceivable changes in our lives and have almost gotten used to them. Education has been done differently, with many children left behind academically at a time when good mentoring could have changed their lives for the better, but some students have had new opportunities because remote learning can be less expensive and more accessible. Social distancing has also meant social isolation for many people with loneliness, anxiety and depression and we have yet to understand its lasting impact.</p><p><b>The pandemic isn't over yet</b>, which would have been a real shocker had we realized a year ago just how long we would be doing this. When it ends and we tell the story of what really happened, we will be able to answer <b>so many questions</b>. <b>Here are a few that I'm curious about now</b>.</p><p>1. How long will immunity from the vaccine last? Which vaccines will provide the best protection? Will the new vaccine technology (especially mRNA vaccines) result in an avalanche of new medical treatments?</p><p>2. Was the pandemic in some way the first of many worldwide climate disasters and will climate disasters start to be more common?</p><p>3. We know that we reduced carbon pollution and use of fuel during the pandemic in a way that was unprecedented. Will those changes persist?</p><p>4. What will be our new normal with regard to illness behavior? Will we actually stop working or traveling when we are sick? Will we wear masks when we are in crowded places with lots of people?</p><p>5. Will we eat out as much?</p><p>6. Will we all go back to work? Will the Amazon office buildings in Seattle fill up or will they be repurposed? </p><p>7. Will Covid variants mean we have seasonal Covid like we have seasonal influenza? If so, how will we deal with it? Will we tolerate it better as it evolves? Will we find some more effective anti-viral medications?</p><p>8. How will the still raging Covid epidemic in poorer countries be controlled and will the need to share vaccines be a model for globalization of resources? Will this help us understand global interdependence better?</p><p>It seems like Covid 19 is starting to wind down in the America. I'm fully vaccinated and so are nearly 20% of the US, or 65 million people. Some people who were hesitant are becoming enthusiastic, and in a few days everyone in the age groups in which the vaccine has been tested (not children) will be eligible. There will be adequate supplies of vaccine. May this be a better year.</p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com1tag:blogger.com,1999:blog-1350181109033523476.post-63950374568823882582021-01-24T15:11:00.001-08:002021-03-29T17:14:45.448-07:00Post Covid-19 Syndrome: dying of Covid is terrible, but some people get sick and just don't get well<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi97pAl5YvlDhHovDnezATQxTY0_pBn0ICDi92ocpGHWcu8lMZGs0vN0dq4nknhB4oDrarZudzu_DZAentNZ_2kKID06Mo51QlEu5O6FjLPBJGsC3QwzbKRf2DJxsvsOqsj217BsfmIurc/s2048/IMG_5163.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi97pAl5YvlDhHovDnezATQxTY0_pBn0ICDi92ocpGHWcu8lMZGs0vN0dq4nknhB4oDrarZudzu_DZAentNZ_2kKID06Mo51QlEu5O6FjLPBJGsC3QwzbKRf2DJxsvsOqsj217BsfmIurc/s320/IMG_5163.jpg" /></a></div>In my present job in a low cost health clinic I don't see much acute Covid. Patients in the infectious stage of the coronavirus are dangerous to everyone they breathe on and potentially infectious virus particles can survive on surfaces in clinic, putting staff and other patients at risk. We see most patients who are still infectious in their cars or we arrange video or telephone based visits. If they are very sick, they need to go to the hospital. Sometimes I feel guilty that I am not taking care of these very sick patients, but that's not my role right now. <p></p><p>The people I do end up seeing are patients who have had Covid, should have recovered, but are still sick. There are many of these people. These are young people, in their 20's maybe, who got sick, tested positive, took 2 weeks off of work, but then can't function normally when they try to go back. They are older people, often with other chronic diseases, who were doing fine but now can't take care of their housework or walk or remember things. They have fatigue, they can't sleep, they can't taste, they are short of breath or have chest pain. They are depressed and anxious. Some of them are uninsured and are living off of family or stimulus checks. Some of them are probably living off of nothing and I am not seeing them at all.</p><p>In some of these patients, especially those who had the disease early on in the pandemic, we don't even have a positive Covid test to guide us. They had symptoms that were entirely consistent with the disease, but early on we didn't have tests and they were turned away. Or they eventually tested negative because either they or we delayed testing even though they had a close family member with confirmed disease and classic symptoms. When they were tested, virus was no longer possible to detect. These patients are particularly frustrating because they now have a mystery disease and nothing shows up on tests and nothing we do makes them better.</p><p>The Infectious Disease Society of America (IDSA) just recently published an updated review of the articles that address "long Covid" or "post Covid-19 syndrome." Some people call these patients "long haulers." One year into the epidemic in the US and 8 months into our huge outbreaks we are just starting to understand how serious this disease can be for people who survive it. </p><p></p><ul style="text-align: left;"><li>In a study for <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32656-8/fulltext">The Lancet</a> of Chinese patients who had been hospitalized with Covid, over 60% had ongoing muscle weakness and fatigue and about a quarter of them had actual measurable inability to walk normally, along with symptoms like sleeplessness, loss of taste, hair loss and lung function abnormalities. The median age of these patients was 57, so we're not talking about just old people. These patients were surveyed 6 months after hospital discharge.</li><li>In the <a href="https://www.acpjournals.org/doi/10.7326/M20-5661">Annals of Internal Medicine</a> patients were evaluated 60 days after discharge from Michigan hospitals. Nearly 25% of patients had died before discharge and of those, only about 75% were well enough to be discharged home. After 60 days, nearly 1/3 of all patients hospitalized had died. Those that did survive had a high proportion of breathing problems, psychological problems and less that half of those who had worked were able to return to full time employment.</li><li>In<a href="https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(20)30606-6/fulltext"> Clinical Microbiology and Infection,</a> a French group looked at patients who had not been critically ill. At 60 days over 2 in 3 patients had some sort of persistent significant symptom. These patients had a mean age of 49.</li><li>In <a href="https://www.journalofinfection.com/article/S0163-4453(20)30562-4/fulltext">Journal of Infection</a> a French study of a single center there showed over half of patients, some of whom had been in the ICU, continued to have symptoms such as fatigue, weakness and shortness of breath over 3 months after their illness.</li><li>In the <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.26368">Journal of Virology</a>, a group out of the UK interviewed patients who were at least 4 weeks from hospital discharge and found that the majority of them continued to have symptoms, especially of fatigue and weakness.</li><li>In a multistate telephone survey from <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm">the CDC </a>of symptomatic adults who had a positive outpatient test for Covid, 35% had not returned to their usual state of health in 2-3 weeks. In young patients, 18-34 years of age, one in five had not returned to normal health. </li></ul><div>This kind of outcome is really unusual for viral illnesses or illnesses in general. We have noticed that patients who are admitted to intensive care units for other reasons and have long difficult courses in the hospital sometimes take a very long time to return to normal. But Covid is not only surprisingly lethal, it also causes an unusual amount of disability. We don't know how long that disability will last, but the proportion of survivors with some kind of disability is really high.</div><div><br /></div><div>Where are the glimmers of hope? </div><div>Vaccines.</div><div><br /></div><div>The Covid vaccines released in the US so far are excellent. An <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2034577">article</a> came out in the New England Journal of Medicine showing what happens to patients after receiving the Pfizer mRNA vaccine. Tens of thousands of patients received vaccine or placebo. Ten days after patients received the first dose of the vaccine they stopped getting Covid. At three weeks, they received their second dose and during the 100 days they gathered data, very few patients who had received the vaccine got Covid and almost nobody got severe Covid. The results with the Moderna version are similar.</div><div><br /></div><div>I got my Pfizer vaccine a little over a month ago. It was fine. I got a sore arm with both doses, a little feeling of "this is weird" after my first dose and one day of low grade fever and muscle aches after the second. I am now very unlikely to get Covid and very unlikely to give Covid to anybody. I participated in a vaccine clinic at the local fairgrounds and there were very few reactions, a few hives, one person who fainted, pretty much par for the course for a vaccine. It was gratifying to realize that all of those patients who passed through that process will be protected. Odds are good that they won't die or become disabled from Covid. The vaccines are apparently still effective even on the newer variants.</div><div><br /></div><div>The fewer cases we have, the fewer disabled people there will be and the less chance to get new and interesting mutant viruses. So. Shots in arms, right away, less virus, more wellness, back to normal, hug your loved ones.</div><div><br /></div><div>One of the many downsides to how many Covid infections we've had is the disability that goes with recovery from the acute illness. Some people have advocated letting the pandemic take its course, welcoming natural "herd immunity" when enough people have had the disease that it can no longer spread quickly. They argue that if we did not shut down businesses or gatherings we would have avoided the economic and social ills associated with these unnatural restrictions. Besides the many more Covid deaths we would have had, there would also be so much more Covid disability, people living with shortness of breath, mental fogginess, depression, weakness and fatigue. The social and financial costs of this disability are already going to be significant. As of today, there have been 25 million confirmed cases of Covid in the US. Experts estimate that at least 200 million people would need to be infected with Covid for adequate herd immunity. We don't yet know how long post Covid related disability will last, but it is sure to have a profound impact on peoples' lives and on healthcare spending.</div><div><br /></div><div>If we can achieve our herd immunity with vaccinations rather than natural infection there will be many fewer sick and dead. The vast majority of people who get a Covid immunization will not be afflicted with Covid, and if we can keep using our masking and social distancing until adequate vaccination happens, millions of people will be spared disability. </div><div><br /></div><div>Not getting Covid is a really important, and worth some inconvenience right now. So at the risk of repeating what may be obvious...</div><div><ol style="text-align: left;"><li>Masking is important whenever you are inside with others or close enough to people outside that you can share aerosols (we say 6 feet.) Cloth masks are not as good as medical masks and N95 or KN95 masks are best. Those little neck sleeves you stretch over your nose and mouth are not helpful in preventing spread of disease. </li><li>It is far less dangerous to spend time with one person alone than to be in a place with many people. It is unlikely that your best friend will be infectious with Covid on the day you spend with him or her. It is very likely that, in a group of 100 people singing in church for instance, or talking in a bar, you will be exposed to infectious respiratory aerosols. </li><li>Get a vaccination as soon as you can. There may be opportunities based on your job or on being the right place at the right time--so take them (sometimes there is an extra dose in a vial, and nobody scheduled to be vaccinated, for instance.) When you are vaccinated you are so much less dangerous to family, friends and strangers. If you and your friends are vaccinated you will be able to socially get "back to normal" with that group. Get vaccinated and you have put on your superhero armor!</li></ol></div><p></p>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-26893134426944634082020-06-07T21:48:00.000-07:002020-06-07T21:48:28.550-07:00What to do about a system that promotes police violence? Shift where the money goes.<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEF8_Ua640fEtRrg271udrsC2iYH6Q7R4vjGIBp4qJB7xsi9UZHCwXzpLHrF3p6V8Ujq24oWSP0XIWmBFNJaYONTbdO6Ho1jwI_86Ro4LScJZAiDFOVUSmxpw5jp1uu1tqYW3H7A-Ld_w/s4032/IMG_3069.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEF8_Ua640fEtRrg271udrsC2iYH6Q7R4vjGIBp4qJB7xsi9UZHCwXzpLHrF3p6V8Ujq24oWSP0XIWmBFNJaYONTbdO6Ho1jwI_86Ro4LScJZAiDFOVUSmxpw5jp1uu1tqYW3H7A-Ld_w/s320/IMG_3069.JPG" /></a></div>I've been thinking about police violence, crime, the criminal justice system and its horrors, racial barriers to success, fear and racism in general. It's been a busy few days as I've tried to educate myself on problems that have been impacting black and brown people for a long time. The video clips that are now circulating are bringing the reality of police violence and disrespect to even people like me, who are protected from that reality by accidents of birth and the privilege of living in a peaceful place. <div><br /></div><div>I've been able to generalize those visuals a bit. I have also listened to the stories of my formerly incarcerated patients. The experience of people in poverty, especially when non-white or vulnerable due to homelessness or mental illness, is that police are to be feared. We are now seeing people die because of interacting with police, but that isn't even the biggest problem. There are far more people who are injured physically, mentally or through inappropriate entry into the criminal justice system. The vast majority of those people are black or brown and this treatment is a big contributor to their remaining in poverty. We are paying police to do this. This violence is on us, all of us who pay their salaries, know what is going on and do nothing to change it. </div><div><br /></div><div>Which brings up another point: policing and the criminal justice system are huge money making operations, much like healthcare. The dysfunction of both are intimately tied to how the money flows. When things like healthcare or crime-care become large enough, tremendous amounts of money flow into them. The money is used to pay many people and each of those people is dependent on that flow of money. Whole sectors of the economy feed off of those proverbial tits and will vigorously root for more sustenance. With healthcare, the money pays for hospital buildings, those who build them, insurance companies, hospitals, administrators, labs, doctors, nurses, janitors, producers of our disposable equipment and the garbage collectors to haul it away (to name but a few.) Law enforcement and criminal justice have similar support systems that make up their entourage, their cheerleaders, their interested parties. Powerful forces want both of these systems to get larger, not smaller. For both of these systems, many of us both pay for them and are recipients of their revenue. We're all in this.</div><div><br /></div><div>What to do then? These sorts of things will just get bigger if allowed to do so unfettered. Healthcare is a many headed beast and very difficult to tame. This blog is devoted to exploring its dysfunction, with which I am familiar, and to celebrating its successes. Policing and criminal justice reform are problems that many capable people are working on right now. I wouldn't presume to prescribe a solution. I do know, however, that money can be directed to make changes. Police are paid through city and county budgets, mostly. So are emergency medical technicians and firefighters. (See my <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2019/08/humongous-healthcare-salary-disparity.html">blog</a> about pay disparities and the shameful way we don't pay EMT's a reasonable wage.) How that funding is divided depends on local government and voters can have an impact on those choices. Personally, I would love to see expanded payment for EMT's and firefighters to come out of police budgets. Many of the things that police do, dealing with folks with mental health and substance abuse problems, responding to reports of domestic disturbances, are not what they are best suited to doing. People with skill in empathy and finding community resources would be better in these situations and would probably avoid escalation. Someone with these abilities could provide those services and be paid to take on those duties. Nurses, counselors, social workers and community mentors come to mind.</div><div><br /></div><div>In healthcare one way to increase revenue is to expand the definition of disease. When we change the definition of high blood pressure to 10 points lower than it used to be, we create more patients who need our care. Same with cholesterol levels. In the world of crime and punishment, having excessive numbers of laws defining criminal behavior, especially ones that are only sometimes enforced (thinking of various drug laws, for instance) creates more criminals. Fewer crimes, fewer criminals, fewer police and fewer jails. So decriminalizing certain offenses could reduce costs, leaving more money to create vibrant communities.</div><div><br /></div><div>Downsizing is painful and there is always huge resistance and predictions of catastrophe when it happens. Downsizing police and incarceration is necessary because the system is bloated and not working. We are buying brutality and racial inequality and we are spending a lot of money for it. All of us need to be part of its transformation and economics are vitally important in making that happen.</div><div><br /></div><div>(Disclaimer: I've been listening to lots of people who really understand this stuff. Many of these ideas are heavily flavored by those wise folk.)</div>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-62894500793161350192020-06-05T21:44:00.001-07:002020-06-05T21:44:32.237-07:00People still aren't getting it: Death counts from Covid 19 underestimate actual numbers!<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHhY-oqBeU3QgUgr8ML6zOz8QMdzJGRq2FxmXUGZcHBlxkuhVBbZbGg3Be2lKCC9Rh48uLtOWHbCDSmCXr5rGVWo4V_jJYrVx99vQqfFulmVgAgQwqiw4M8SoQhAZg2jRIVY8DsKzyLpY/s4032/IMG_3113.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHhY-oqBeU3QgUgr8ML6zOz8QMdzJGRq2FxmXUGZcHBlxkuhVBbZbGg3Be2lKCC9Rh48uLtOWHbCDSmCXr5rGVWo4V_jJYrVx99vQqfFulmVgAgQwqiw4M8SoQhAZg2jRIVY8DsKzyLpY/s320/IMG_3113.JPG" /></a></div><div class="separator" style="clear: both; text-align: left;">I have recently become aware that some people are mistakenly getting suspicious that Covid 19 death counts are an overestimate. That is probably because the numbers are awful and very hard to visualize. Nearly 110,000 deaths have been documented so far in the US, which is undoubtedly significantly below the actual number who have died from the disease (see my <a href="http://whyisamericanhealthcaresoexpensive.blogspot.com/2020/03/covid-19-and-death-rates-doctors-know.html">previous blog </a>on the subject, from very early on in the pandemic.)</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Our freshman US representative in Idaho, who serves a dark red district of a very conservative state, recently wrote a letter to the CDC concerned that the guidance they have given regarding filling in death certificates will lead to a falsely elevated number of people who have died of the disease. I just wrote Mr. Fulcher a letter explaining why this is wrong.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><div><b><i>"I saw your letter in your recent email encouraging the CDC to count Covid deaths accurately. I think you may not know some of the nitty gritty of documenting cause of death from a doctor's standpoint. After over 30 years of completing death certificates for patients who die in hospitals, nursing homes and their own homes, I have some familiarity with this. The bottom line is that, when we finally have all the data, our present estimates of deaths due to Covid 19 will be a gross underestimate.</i></b></div><div><b><i><br /></i></b></div><div><b><i>The reasons for this are:</i></b></div><div><b><i><br /></i></b></div><div><b><i>1. 20% of people die at home. For most of these, there is no autopsy and a cause of death is assumed to be something on their known problem list, such as heart attack or stroke or COPD or cancer. Most people who die at home with Covid don't get coronavirus testing and so won't be counted as Covid deaths.</i></b></div><div><b><i>2. From knowing what is happening in nursing homes that are infected with Covid 19, death from that disease looks like this: residents start getting fevers and coughs. They stop eating and getting out of bed. They die. It's often the increase in deaths that clues people in that there is Covid in the nursing home. So most of those people who died from Covid won't have been tested and won't have it on their death certificates.</i></b></div><div><b><i>3. In hospitals for months there was not enough testing kits to go around so when there was clearly an epidemic going on they stopped testing patients with obvious Covid symptoms. Everyone with cough and low oxygen levels had Covid 19. There was no point wasting testing and exposing nurses to more risk of infection by swabbing patients. Doctors don't necessarily feel comfortable documenting those deaths as Covid if they didn't get testing. Many of these were misclassified.<br /></i></b></div><div><b><i><br /></i></b></div><div><b><i>Also--you are asking the CDC to call Covid deaths only if the person died directly of Covid. This is the thing about the comorbidities. When a person has Covid and comorbidities they die of the combination. They wouldn't have died without the Covid, so it is the cause of death. Or at least should be. Some of these patients are being classified as having died due to the heart attack or the COPD exacerbation caused by Covid so they aren't on the official count.</i></b></div><div><b><i><br /></i></b></div><div><b><i>It generally takes a couple of years for the accurate numbers of influenza deaths to get counted by the CDC because they look at more than just the death certificates. With influenza also, most deaths are in patients with comorbidities and if we just counted the ones that said "influenza" on the death certificate it would be a gross underestimate.</i></b></div><div><b><i><br /></i></b></div><div><b><i>Right now we are trying to evaluate the impact on deaths due to Covid by looking at death rates now vs in previous years. That will underestimate the numbers of Covid deaths as well because with lockdown people didn't go out and get killed in car accidents, they didn't mix with others and die of other infectious diseases and they didn't suffer other trauma as much. So without Covid we would have been much healthier in lockdown. <br /></i></b></div><div><b><i><br /></i></b></div><div><b><i>I would encourage you not to worry about the death count from Covid being inaccurately high. The CDC is really good at figuring this stuff out having done it for years with influenza. What you are seeing is falsely low numbers because that is the best we can do right now."</i></b></div><div><b><i><br /></i></b></div></div><div>Just thought I would share. </div><div><br /></div><div>What I didn't mention to Mr. Fulcher, who in my one experience of him, at a town hall meeting, would not be very interested, is that death rates in the developing world are likely even less accurate than our own. In Tanzania, for instance, they have decided that people will be happier if they don't know what is happening with Covid 19, so after initially testing a few people they have stopped. In Brazil, they are reporting 35,000 deaths so far with over 600,000 cases. But 20% of Brazilians live in poverty and so probably die without receiving medical care. In many developing countries it may be years before there is a way to estimate the numbers of infections and deaths. India, which has very advanced medical care for those who can access it, also has huge numbers of people living in extreme poverty, many of them in crowded conditions with multigenerational families. Over 80% of Indians die at home. I'm not sure how they can accurately document causes of death there.</div><div><br /></div><div>Much like the influenza pandemic of 1918-1919, we will not know the accurate numbers for many years. And like that influenza outbreak, we are far from being done with coronavirus in June of 2020.</div>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com1tag:blogger.com,1999:blog-1350181109033523476.post-72816796807452816532020-06-01T16:39:00.001-07:002020-06-01T16:39:37.639-07:00In solidarity with people protesting the killing of George Floyd<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiszEWvmOjRs9XLAuY6jfq3YWLOsdlV_18vjbOR6RtwyjWj5bjr6E1Q-9p0TqsI884C4ZfPa4H5J2czTUO6TGDd4gUc-eVJkh5Qjt1EdZhR_BxMP3PjRcXvBZj4VlYM9BulkXF6KzGWUsQ/" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="3024" data-original-width="4032" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiszEWvmOjRs9XLAuY6jfq3YWLOsdlV_18vjbOR6RtwyjWj5bjr6E1Q-9p0TqsI884C4ZfPa4H5J2czTUO6TGDd4gUc-eVJkh5Qjt1EdZhR_BxMP3PjRcXvBZj4VlYM9BulkXF6KzGWUsQ/s320/IMG_3018.JPG" width="320" /></a>I am not especially qualified to write on the subject of racism or the militarization of policing or how the criminal justice system perpetuates poverty and loss of opportunity based on race. I am white, grew up in predominantly white neighborhoods and have always had certain expectations based on those privileges. Like most people I have my own story flavored by my own challenges. None of these challenges are based on race.<div><br /></div><div>I have watched from my safe community where police generally act like good people. (Obviously this is from my standpoint which may not represent everyone's experience.) As a doctor I have cared for police refugees from big cities, retired officers whose experiences of police culture drove them away and marked their personalities. I have enough connection with people on the receiving end of the criminal justice system in other communities that I am not entirely ignorant, but my experience is definitely limited.</div><div><br /></div><div>So in this time of Covid 19 and now widespread demonstrations and rioting, I feel pretty helpless and useless to influence the changes that are needed to make things better. As an unwilling bystander (I will gladly do anything I can to contribute) I will at least say on this blog:</div><div><br /></div><div><ul style="text-align: left;"><li><font size="4">The lives of black and brown people are sacred and they deserve respect, opportunity and to be safe from injury by law enforcement.</font></li><li><font size="4">The criminal justice system needs significant reform so that it will contribute to helping pull people out of poverty rather than chaining them to it.</font></li><li><font size="4">The illnesses of poverty, violence, drug and alcohol abuse need to be managed first and foremost at the level of opportunity through education, jobs and healthy communities.</font></li></ul><div>I will do my best to support people who are standing up and marching to be heard by donating to organizations such as <a href="https://bailproject.org/">The Bail Project</a> that at least help give people in the system a hand. </div></div><div><br /></div><div>As a physician and an old person (I was young once and politically active) I am concerned about a couple of things. I hate to see indiscriminate destruction, especially in neighborhoods that are already poor. I would like to see more people aware of the fact that we still have a pandemic going on and that we know that close to 50% of people who are infective with Covid 19 have no symptoms. Wearing masks to a demonstration is a no-brainer. If you don't believe in the germ theory, at least it keeps your beautiful face from becoming a viral news photograph. And I'm angry that people who want to fan the flame of anger and fear are doing so, either by using inflammatory rhetoric or by actually physically inciting or committing violence.</div><div><br /></div><div>But despite these issues, the real and important point is that George Floyd was killed by police officers who thought, because of their training and institutional culture, that it was OK, and this is only the tip of an iceberg of widespread police violence in black communities. The demonstrations and the anger they represent is real and needs to result in real change.</div><div><br /></div><div>(President Obama had some great things to say about how to go about making those changes in <a href="https://medium.com/@BarackObama/how-to-make-this-moment-the-turning-point-for-real-change-9fa209806067">this article</a>. It's a brief and inspiring read.)</div>Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-24465746813885985902020-04-09T21:07:00.000-07:002020-04-09T21:07:36.140-07:00Covid-19 Quarantine: are we afraid of going back?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijDlQBJ-xIhn7T9u0oIWCWOkBtMri51jQLUkap2eZktbYawXNAH78q-IwAdKFJ5LiMuf3F1-H35Rqg4IjVXCKE2wn-7tC7XjUfg6RSZgYnvmm4u6dpVfJucTSyHiqheh3b-1LgnL7xO_g/s1600/IMG_2694.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijDlQBJ-xIhn7T9u0oIWCWOkBtMri51jQLUkap2eZktbYawXNAH78q-IwAdKFJ5LiMuf3F1-H35Rqg4IjVXCKE2wn-7tC7XjUfg6RSZgYnvmm4u6dpVfJucTSyHiqheh3b-1LgnL7xO_g/s320/IMG_2694.JPG" width="240" /></a></div>
It is 2 weeks since Governor Brad Little of Idaho issued a statewide <b>"stay at home"</b> order and about 3 weeks since my little town has been staying at home because of an earlier mayor's order. The whole US has been increasingly moving toward self quarantining. People throughout the world are being asked to avoid sharing space and sharing germs with others. Buying and selling and traveling aren't happening much. There is very little going to school, receiving non-essential services, partying, touching or breathing on people outside of our immediate biological or chosen families.<br />
<br />
Some people are getting bored. Many are feeling challenged by having to do things that aren't normal for them, things like cooking, cleaning, childcare. Many of the things that filled our days are just not happening. <b>There is a whole lot of quiet.</b><br />
<br />
<b>The creativity that is happening in the absence of whatever it was we used to do is pretty stupendous</b>. People are writing for each other and making music. They are doing crafts and sharing the how-to's online. Very rich people have nothing much to do with their money and are donating it to causes or initiating projects aimed at improving the situation, but also improving the world in general.<br />
<br />
There are also new and <b>familiar terrible things</b> going on such as the poor getting poorer and relationships strained to breaking because of too much togetherness. Some people are drinking too much alcohol or doing too many drugs or gaming until their eyes cross and they develop bedsores on their nether parts. We all react to stresses in different ways.<br />
<br />
Skies are going from dirty brown to <b>brighter shades of blue</b> as air pollution from factories and cars recedes. Pandas are mating in a spectator-free zoo for the first time in I'm not sure how long. Wildlife is coming back to cities. We are producing much less carbon dioxide and much less waste in general.<br />
<br />
In medicine, my field, all kinds of changes are happening. In places where people brought the novel coronavirus from distant parts and then mixed with other people in close quarters, places like New Orleans, New York and Detroit, hospitals are hopping and people are dying partly due to having overwhelmed the medical system. But in these busy places, <b>doctors and nurses and aides and administrators are using ingenuity to solve problems</b> that have been around forever but are now critical. In smaller towns we are slower to experience the epidemics and are still in a state of quiet waiting. Few people are seeing doctors for problems that don't seem to need immediate care. My days are slow and I am able to concentrate fully on each patient I see (or talk to, as the case may be.) It's a little eerie.<br />
<br />
We have all made changes. My colleagues and I are talking to patients on the phone or seeing them on a video monitor rather than bringing them in to the clinic where they can infect us and we can infect them. It is not ideal, but it is not terrible. In fact, <b>some of these "virtual visits" are more appropriate for a patient than coming in</b>. In hospitals physicians and staff need to conserve personal protective gear like masks and gowns and so they are batching care, one person will bring in a meal tray, check a blood sugar, hook up an IV bag, pass a medicine, draw a blood test, change a dressing, all in one fell swoop. One person, one exposure, one set of protective gear. Also this is great for a patient who usually gets disturbed and woken many times in a day, interrupting the rest that would be healing. This means that we do need to adjust our dosing of medication so it corresponds to mealtimes, but it turns out that works just fine.<br />
<br />
Some hospitalists who are at higher risk of infection or who need to self quarantine work from home to provide night coverage. They can take calls from the hospital about routine questions, allowing the doctor in the hospital to sleep or concentrate on work at the bedside.<br />
<br />
Good stuff, but also balanced by alarming economic devastation, with huge numbers of people suddenly unemployed with no obvious way to pay for necessities. <b>Despots are grabbing power and painting human rights as optional.</b> Leaders are undoubtedly getting away with all sorts of hanky panky while citizens are otherwise distracted. There is the ongoing tragedy of disability, pain and death from the disease itself.<br />
<br />
And also the very real strangeness for all of us, as social and tribal animals, now <b>unable to casually touch and mingle.</b><br />
<br />
<b>We are all ready for this to be over. But maybe not...</b><br />
<b><br /></b>
Besides wanting some of what we had before being told to stay at home, many people voice that they <b>don't want to return to the way things were</b>. I think people are a little worried that we won't have learned anything. That we will return to wasteful excesses of travel and spending and expensive oversized sparkliness. That we will forget that we are all so very connected when there is no deadly virus to connect us. No worries. We will not be going back. It is not at all clear what the configuration of the world will be when this is all over, but Covid-19 has become part of who we are.<br />
<br />
These are a few of the <b>things that can't be undone:</b><br />
<br />
<ol>
<li>We have found out that at least <b>some of us can get a lot of things done from home, without going in to work.</b> This saves resources of many kinds: fuel for commuting, office space at which to confine us, childcare...We can be more flexible with work hours which would allow us to serve working people better and coordinate with colleagues in different time zones. Businesses would have to be crazy not to take advantage of this.</li>
<li>We have noticed that <b>we don't need to spend so much money</b>. Many of us have been spending much less money in the last few weeks by not going anywhere. As a world, we are also not doing some of the very costly things that we did do, things like the Olympics or big conventions or professional sports. It will be nice to have some of that back for sure, but we will have survived just fine without it. This will have a durable economic effect. If we spend less money, we need less money and that means that we don't really have to work as hard or as long. It won't be seamless (people in poverty will still need to work just as hard because they had no excess spending) but overall we know we can consume less so we can also produce less.</li>
<li>In healthcare we have proven that <b>leaving a significant number of people without access is neither humane nor practical.</b> That a business model for delivering care, with a workforce just large enough to take care of our usual number of patients, minimizing infrastructure and lacking the ability to expand will leave us in a terrible situation at times like this. We will have to see that it is very expensive as well as tragic when we do this wrong.</li>
<li>We have learned that there is an <b>astounding generosity of spirit</b> among regular people: generosity of time, money and courage. That we can do amazing things when we really want to, and we really want to take care of each other.</li>
</ol>
Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com2tag:blogger.com,1999:blog-1350181109033523476.post-88444797745320524632020-03-27T21:44:00.000-07:002020-04-09T21:36:27.693-07:00Covid-19 and death rates--doctors know why numbers of people who have died are wrong<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQROXBLfcpxs7aj8IfwkHWU7PuWBZ7IKbYXUcPFG2Y4k8Bl7tM1rl0F6H0uxNF81M1llIcwfrcAE00yqz6lUegMc-v1DdQiXStTUVHrIvuGU9VD1W_6xBBlRQMBesq794q7F_gN5vkP98/s1600/IMG_2606.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQROXBLfcpxs7aj8IfwkHWU7PuWBZ7IKbYXUcPFG2Y4k8Bl7tM1rl0F6H0uxNF81M1llIcwfrcAE00yqz6lUegMc-v1DdQiXStTUVHrIvuGU9VD1W_6xBBlRQMBesq794q7F_gN5vkP98/s320/IMG_2606.JPG" width="240" /></a></div>
This morning the total number of deaths in the US from Covid-19 was said to be 994. That sounds kind of low, since influenza has already killed 30,000 this season. In the places where coronavirus has hit hard, it's much worse than the flu, in New York and New Orleans for instance. People are much sicker and the whole healthcare system, including emergency medical services, is stressed to breaking. We know that coronavirus is more severe and more contagious and more deadly than the flu by at least a factor of 10. Why are the numbers of deaths presently so low?<br />
<br />
The thing that nobody is talking about with regard to Covid deaths is that our data about who has died is going to lag by weeks, months or even years and will probably fail to represent all of the deaths for which Covid is responsible. Why is this?<br />
<br />
<ol>
<li><b>People are dying at home of Covid.</b> How do I know this? <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6513a6.htm" target="_blank">Because 25% of people die in their own homes.</a> People with symptoms of coronavirus are being encouraged to stay at home so some proportion of them, likely older or with disabling diseases, are dying there. <b>When a person dies at home, unless it is a hospice death, the process of certifying their cause of death can be quite prolonged.</b> Sometimes a coroner is involved and it can take weeks.</li>
<li><b>It takes a long time to die of an acute disease in the hospital.</b> We work really hard to keep a patient alive who has been intubated and admitted to the ICU. We will try all sorts of procedures to make the lungs work and, even as the lungs get worse, we still find new machines or drugs to keep them alive with the hope that, if they survive long enough, their lungs will heal. Some of the patients in New York hospitals who are on death's door will remain there for weeks until either their bodies or their families finally give up. <b>It could take weeks after coronavirus infections start to peak to know what percent of those infected people will die of the disease.</b></li>
<li><b>Doctors working with patients who are dying are very tired, and one of the least pressing things on their to-do list is to fill out death certificates</b>. Some of that documentation is waiting in an exhausted physician's in-box to be completed.</li>
<li>In the busiest hospitals and most infected communities, patients with definite Covid-19 aren't being tested because there is no time and it becomes clear what is wrong with them because of their symptoms. <b>When doctors fill out death certificates they may not list Covid-19 as the cause of death.</b> I just recently got an email from the Idaho Death Registry telling me to put Covid as the cause of death if this is my educated opinion, even if the patient wasn't tested. It is likely that many physicians don't know this is the correct way to do it.</li>
</ol>
<div>
<span style="background-color: white;">All of these factors are probably also affecting other countries' reported numbers of deaths. This means the numbers of the sick and dead worldwide are probably higher than we believe.</span></div>
<div>
<span style="background-color: white;"><br /></span></div>
<div>
<b>A note on why so many people die of the flu compared to how many have died of Covid-19:</b></div>
<div>
<b><br /></b></div>
<div>
Obviously, we are early in the epidemic and the numbers are rising daily. They haven't come close to peaking. But that's not even the biggest problem with this comparison.</div>
<div>
<b><br /></b></div>
<div>
The <a href="https://www.cdc.gov/flu/about/burden/how-cdc-estimates.htm#References" target="_blank">CDC calculates deaths of the flu</a> in a very complex way. It is not the same way they are calculating deaths of Covid-19. With influenza CDC epidemiologists do not just count the number of people with positive influenza tests who die directly of that acute illness. They start by using the number of positive flu tests corrected for the fact that the test is insensitive (misses a significant percentage of people who are infected). They then get a bigger number by looking at the fact that most people with the flu are never tested. They also use death certificate data, but in a very nuanced way. <b>The actual number of deaths from influenza includes people who die of other things that become fatal because of influenza, things like heart failure or chronic lung or vascular disease.</b> On many of those death certificates, influenza will not even be listed. Some of those deaths happen weeks after an episode of the flu. It takes years to come up with an accurate death count for a particular year. </div>
<div>
<br /></div>
<div>
At this point we don't, and we can't, calculate the deaths of Covid-19 the same way we do influenza. In the words on the CDC website: "<span style="background-color: white;"><span style="font-family: inherit;">Only counting deaths where influenza was recorded on a death certificate would be a gross underestimation of influenza’s true impact." To extrapolate from that, <b>only counting deaths where Covid-19 is recorded on the death certificate will be a gross underestimate of this disease's true impact. </b>Comparing reported numbers of people who have died of coronavirus so far to deaths from influenza is <i>extremely</i> misleading. <b>Deaths due to influenza and Covid-19 are being calculated completely differently. </b>When this epidemic is finally over, a number such as 994 on March 27 will be a point on a timeline representing the early part of America's experience, a point when we had only an inkling of what it would be like.</span></span><br />
<br /></div>
Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com1tag:blogger.com,1999:blog-1350181109033523476.post-57312084759791971632020-03-24T22:05:00.000-07:002020-03-24T22:08:01.256-07:00Sex in the time of Covid-19<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi34eWM7CUHQerhj1e1JzGQHTNLwyz-uhAnIJTIpm4PdiykwUWZFKD1ggrySCXJek1c1k1Nbx4rGdOxlgkw8rSusu9oCE9dXO53ar8XWJVrrHgfHQ0p5CPk7uG-TCY5zRG9Pnxv3jPv3yQ/s1600/IMG_2264.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi34eWM7CUHQerhj1e1JzGQHTNLwyz-uhAnIJTIpm4PdiykwUWZFKD1ggrySCXJek1c1k1Nbx4rGdOxlgkw8rSusu9oCE9dXO53ar8XWJVrrHgfHQ0p5CPk7uG-TCY5zRG9Pnxv3jPv3yQ/s400/IMG_2264.JPG" width="300" /></a></div>
When we are all trying to avoid deadly spread of coronavirus infections, <b>can we still have sex</b>?<br />
<div>
<br />
<div>
This is a GREAT question. Luckily the New York City department of health has answered this and many more questions you may hesitate to ask in their very complete and unabashed 2 page <a href="https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf" target="_blank">primer</a> on the subject. <b>Please follow the link.</b> It is a brilliant document leaving just enough to the imagination.</div>
<div>
<br /></div>
<div>
The most controversial and absolutely true statement they make is that <b>"You are your safest sex partner."</b> </div>
<div>
<br /></div>
<div>
Sex is the most physically intimate activity that most people engage in. Coronavirus is transmitted when virus from one person's respiratory tract (usually lungs, mouth or nose) finds its way to another person's respiratory tract where it infects vulnerable cells. Not all cells are vulnerable. Coronavirus is found in certain other body fluids but it is less practical for the viruses in, say, stool or tears to be involved in transmitting infection. But sex between humans just about always involves two people creating respiratory aerosols. <b>We can assume that having sex is extremely good at transferring coronavirus from one person to another</b>, and that there is virtually no practical way to have safe sex with a person who is shedding the virus. Most likely it's just the kissing and heavy breathing that is the dangerous part rather than the part that involves genitals.</div>
<div>
<br /></div>
<div>
So when there is an outbreak like this it is a terrible idea to be physically intimate with anyone new. </div>
<div>
<br /></div>
<div>
It's important to evaluate your risk of infecting others or being infected by others according to <b>how many contacts you have</b> and <b>how intense </b>those contacts are. The clerk at the grocery store has had some contact with hundreds of potentially infected people every day and when you contact that clerk, you are, in effect, in second hand contact with all of those people. But since you barely breathe the same air as the clerk, the risk is tolerable. If that clerk was also a daycare worker who was in close and messy contact with many potentially infected children, the risk to you is higher. If the clerk also coughs right in your face or he is your husband, you have many high risk intimate second hand contacts.</div>
<div>
<br /></div>
<div>
Sex is like that. If you were <b>unwise enough to go out on a Tinder date with some guy</b> who you only know from his curated content, he might in fact be an international cage fighter. If the date got hot and heavy, you would have intimate second hand contact with all of those other international cage fighters (or pro basketball players or whatever) because your new beau had deeply inhaled all of their very high risk respiratory aerosols. <b>This guy might not feel sick at all, or maybe just a tad under the weather, and still be shedding virus like crazy.</b> In fact, with all of those high risk contacts, he would be more than likely to be infected. </div>
<div>
<br /></div>
<div>
The safest of all contacts at this time is none at all. This is impractical for most people. Second is to limit contacts to only a household and make sure that household limits their contacts to you. Once you start hanging out with people with many high risk intimate contacts, your risk of contracting the virus goes way up and then you are sick and are the person infecting others. So think about it. If you are hooked on online dating, keep it online. Think of it as a <b>long courtship.</b> By the time you meet this guy in person after weeks or more of quarantine you'll be pretty sure he's not a jerk.</div>
</div>
Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-55418295423960750062020-03-22T23:15:00.002-07:002020-03-23T20:54:31.791-07:00Things everybody should know about Covid-19. Plus some ideas.<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYP9Jm8Yz2kn937hyphenhyphenUVu38kQfT5CgVGMbyRvZ-Z_Vkl0cvwZhyphenhyphentKHcG9ao2OBT70Ow2nO5CZE7sNN6CikDIuxuJ3Owy1A27SmzjyK9Jn6XYIPHkqf5YXTu1uJwbtb_RPl7jXY3II3z0FM/s1600/IMG_2227.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYP9Jm8Yz2kn937hyphenhyphenUVu38kQfT5CgVGMbyRvZ-Z_Vkl0cvwZhyphenhyphentKHcG9ao2OBT70Ow2nO5CZE7sNN6CikDIuxuJ3Owy1A27SmzjyK9Jn6XYIPHkqf5YXTu1uJwbtb_RPl7jXY3II3z0FM/s320/IMG_2227.JPG" width="320" /></a></div>
Idaho has 42 cases of Covid-19 as of this morning. It feels like nothing, but that's because very few people are being tested and we are on the leading edge of the exponential growth curve. Some of us feel bad for feeling happy because these are serious times, some people feel sad in expectation of feeling sad in the future and others are just scared. It feels a little like a snow day, though, and we are knee deep in possibilities. Young people who never cook are learning to cook. People are doing crafts and hunkering down. I've heard from friends who I'd lost touch with. Much of my day is eaten up by learning more of what's known and what's known today may be wrong tomorrow.<br />
<br />
Things you should know which are likely to be true:<br />
<div>
<br />
<ul>
<li>The coronavirus has a median <b>incubation period</b> of just over <b>5 days</b> and nearly everyone who gets it will get it within <b>12 days</b> of exposure. This is from China's data, <a href="https://www.jwatch.org/na51083/2020/03/13/covid-19-incubation-period-update" target="_blank">reported</a> in the Annals of Internal Medicine. </li>
<li><b>Symptoms</b> can be variable: <b>muscle aches, sore throat, fever, chest tightness, cough, runny nose, fatigue, nausea, vomiting, diarrhea, loss of sense of smell</b> (later in the disease). There can be no symptoms at all! Symptoms can be <b>long lasting</b> and can get better and then worse again for weeks. This is from a combination of the New England Journal and self reports from physicians I know. </li>
<li>The nasal secretions of patients in China who show <b>no symptoms have the same number of viruses in them as those who do show symptoms</b>. If they aren't coughing and sneezing they probably aren't transmitting it as much, but that's the only difference. Source: <a href="https://www.nejm.org/doi/full/10.1056/NEJMc2001737" target="_blank">NEJM</a>.<span id="goog_330776505"></span><a href="https://www.blogger.com/"></a><span id="goog_330776506"></span> (Please note: Senator Rand Paul is reported to have tested positive but has no symptoms. He was reported to have then gone to the gym and attended a lunch with other people. That was foolish and very risky for other people.) <b>So: just because a person has no symptoms does not mean they will not give you Covid-19. They definitely can.</b></li>
<li>Around 15% of Chinese children who were infected had no symptoms. None at all. A proportion of these showed some sort of viral pneumonia when they were scanned. It is very hard to know what the spectrum of disease is in asymptomatic patients in the western world because we are testing very few people without symptoms. So <b>Covid 19 infection is real even if the person carrying it feels OK.</b> This is from the <a href="https://www.nejm.org/doi/full/10.1056/NEJMc2005073?query=featured_home" target="_blank">NEJM</a>.</li>
<li>It appears that <b>virus survives on dry surfaces</b> for longer than you might think but not forever. A recent US study shows a range of a few hours to about 3 days (<a href="https://www.nejm.org/doi/full/10.1056/NEJMc2004973?query=featured_home" target="_blank">NEJM</a>). This means that it might survive on the package handed to you by a sick UPS driver. The surface of that box, though, will have fewer and fewer infectious viruses as time goes on and 3 days after its last exposure to live viruses all of the virus that might have been on its surface will be dead. Your package will not create aerosols so you could open it and then clean your hands after throwing away the packaging. This goes for takeout boxes, cardboard coffee cups etc. The coronavirus does not go through your skin so in order for you to be affected it has to get to your nose or other respiratory mucosa. <b>Clean your hands after handling things that others touch. Keep your hands away from your face, especially your nose.</b></li>
<li>The nasal and pharyngeal swabs miss some patients who are infected. This is Chinese data, so could be different in the US. For the test to detect infection, it must be an accurate test and the sample must be good (that swab goes WAY up your nose and maybe not everyone is doing it correctly.) <b>We may be missing 30-40% of patients who are infected even if they get the test</b> (<a href="https://www.jwatch.org/na51116/2020/03/17/pharyngeal-and-nasal-swabs-may-not-have-adequate" target="_blank">JAMA</a>).</li>
</ul>
</div>
<div>
<div>
<br /></div>
<div>
Things to do (when you can't do much): You may be suffering financially already, but maybe not. Helping people out now may not only be good for them but will likely blunt the devastation that will follow this great experiment in stopping everything.<br />
<br />
<ul>
<li>If something you were planning to do is canceled, consider not asking for a refund.</li>
<li>Buy gift cards at restaurants, bookstores, anywhere that is hurting right now. Either throw the gift cards away or save them and use them when the business is back to thriving.</li>
<li>Give big tips when you get take-out.</li>
<li>Start turning money into real value by helping your friends and family pay off loans or bills. You may have to bring this up. They may not ask. </li>
<li>Start giving to charity again. Some people have stopped because the tax bill that congress passed in 2017 has made it harder to deduct charitable donations. Think it through. What charities are going to really make an impact? Food banks. Churches with a strong commitment to helping the poor. Homeless shelters and drug and alcohol recovery centers. Arts organizations. Really. Arts organizations are hurting, will get very little federal support and employ vulnerable gig workers. </li>
<li>Support your local artist. Buy something cool online from an actual artist. Check out Etsy perhaps.</li>
</ul>
</div>
<div>
<br /></div>
<div>
The great reset:<br />
<br />
We are going to be slowing down for awhile. This is a marathon not a sprint. Correction. This is a very long and challenging walk on the Appalachian trail, without all the company. It may seem hard but we're going to get better at it and it will change. Oh the things we're going to know in a month that we don't know now! That was always true but we were too busy to notice. Pay attention and remember. These will be good stories to tell eventually.</div>
</div>
Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com3tag:blogger.com,1999:blog-1350181109033523476.post-1001747896116577682020-03-21T11:38:00.000-07:002020-03-23T13:36:49.898-07:00PPE--personal protective equipment. How we can have enough in the era of Covid-19.<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqCc19-9j1lofw1H_I5nztFeO1OvOPOStdyP00zlOafr103PG8oduNKaK9fN8AuNNmrRPULdug9t2XZCGvZOri0fGG05ISyx7As5PjKAzpogWSC3V2SeOObc1kuqmD8CumY3gZHjK2vOY/s1600/IMG_2625.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqCc19-9j1lofw1H_I5nztFeO1OvOPOStdyP00zlOafr103PG8oduNKaK9fN8AuNNmrRPULdug9t2XZCGvZOri0fGG05ISyx7As5PjKAzpogWSC3V2SeOObc1kuqmD8CumY3gZHjK2vOY/s320/IMG_2625.JPG" width="240" /></a></div>
We doctors are worrying about shortages of personal protective equipment. PPE is what we call it. When we see a patient with a disease that could be transmitted to others, we wear things that cover our bodies that can either be washed or thrown away. Infections can be spread by contact, by droplets or aerosols. We have different precautions for each type and within these categories, what we do depends on precisely which kind of infection we are worried about. We also, since the advent of HIV, use "universal precautions" to protect ourselves and our patients from bloodborne pathogens that we may have no reason to suspect but might be present anyway.<br />
<br />
Universal precautions include wearing gloves for any procedure that involves contact with a patient's blood or body fluids or presents a significant risk for that, such as drawing blood or cleaning wounds.<br />
<br />
Diseases such as influenza or certain pneumonias are transmitted by droplets. For those infections we need to use a mask and ideally the patient will use one too. Contact precautions, requiring the use of gowns and gloves, cleaning equipment we use on the patient before re-use, is for things like infectious gastroenteritis (stomach flu, norovirus), Clostridium difficile and resistant bacterial infections such as MRSA. Airborne precautions are for diseases such as tuberculosis, measles and chickenpox. Those require a mask that filters out most particles. The N95 mask filters out 95% of airborne particles. The N stands for "not" oil resistant since these masks are also used for industrial particle protection. We also use a helmet type device called a PAPR or powered air purifying respirator. This has a little battery powered HEPA filter that creates airflow inside a plastic shield that hangs off of a well fitting lightweight helmet.<br />
<br />
Covid19 is carried by droplets but viruses also can move as an aerosol. The arosolized viruses can float further than a droplet and when the virus lands it is viable for hours to days. Protection in this case includes droplet, aerosol and contact precautions. So that means we should use a gown, gloves and a mask at least as good as an N-95. N-95 masks work if they have been fitted to a person's face and don't allow air around the sides. When I was fitted for my N-95 mask, a skilled occupational medicine nurse at my hospital found the right size and showed me how to put it on. She then put a hood over my masked head and sprayed a few small but pungent particle sprays in the hood to see if I could taste or smell them. The small size mask fit me well so that is the size I wear. Nobody in my clinic that I know of has been fitted for N-95 masks and we don't have any in my clinic anyway. We use the much more common surgical mask that is only effective for droplet transmission or a PAPR for very high risk patients. We also use gloves and disposable gowns. All masks and gowns and perhaps gloves are available only in the numbers that we normally use, so we're going to run out in places with a high volume of visits. We will run out even in places where Covid19 doesn't overrun us because we will be using them, appropriately, for everyone we suspect of having it.<br />
<br />
The good news is that the virus causing Covid19 does not live forever on dry surfaces. A group of researchers in Hamilton, Montana <a href="https://www.nejm.org/doi/full/10.1056/NEJMc2004973?query=featured_home" target="_blank">looked at</a> the survival of virus on various dry surfaces and found that it survives best on metal and plastic, up to 72 hours, but less well on copper or cardboard. This means that it would be possible to "quarantine" our masks and gowns for some number of days and re-use them in rotation. This would be especially safe in equipment we used just to be super safe around a person with a cough or sore throat who turned out to be very unlikely to have Covid19. If we put the (not grossly soiled) PPE in a bag with a date on it we could be quite sure that it would be safe to re-use after 5 days. This will not help the hospitals already at the end of their supplies. There will also be attrition of PPE as it gets ratty, torn, soiled or breaks. We still need all of the ideas for increasing supply of this stuff, especially to the hardest hit areas of the country.<br />
<br />
Be aware, though, that the longer the virus is away from the host, the less infectious it will be. This applies to our home situations as well. Right after being sick with this virus our homes will have viable virus around. When we are well, however, it won't take long for the virus in our environment to be well and truly gone. Cleaning and disinfecting may be a good idea but once people in the home are well and immune it won't be strictly necessary.<br />
<br />
Making masks out of cloth is probably not terribly useful except in situations of dire need since it would be very difficult to make a mask that was able to protect against aerosols. But droplet protection is better than nothing, especially for people working outside of healthcare. I saw a hilarious and probably effective mask from Tbilisi, Georgia, on a guy in a bus. It was a 5 gallon water bottle with the bottom cut off, attached to a sweater, with a baffle at the neck of the bottle which was at the top. Not attractive, certainly, but most likely very effective. Also encourages social distancing!Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com0tag:blogger.com,1999:blog-1350181109033523476.post-45000540405836964332020-03-20T22:26:00.000-07:002020-03-22T00:09:28.314-07:00Covid-19 why does it seem like nothing is happening? #mycoviddiaryIn and around town there are people who are looking at all of the rest of us who are hand sanitizing and social distancing like we are crazy. I feel for them. They are simply trusting their own experience. They don't see people dropping like flies. Nobody they know even has a cough. Restaurants are closing and it looks like everyone is needlessly panicking. What gives? Why are they wrong?<br />
<div>
<br /></div>
<div>
The reason it seems like nothing is happening while governors and doctors are predicting huge numbers of people who will be sick and dying is something called <b>exponential growth.</b> That means that the number of cases of this disease are increasing <i>faster</i> each day. In a time of exponential growth things seem really mellow at first, as the number of cases goes from 2 to 4 in one doubling time, just 2 more cases, what's the big deal? Then the next doubling time the 4 cases become 8, but that's not so bad, just 4 more cases. Days go by... when you get to the tenth doubling period with 1024 cases and that number doubles <b>it isn't funny anymore</b> because the next day there are 2048 people with the disease, 20% of whom need to be in the hospital and your hospital only has 25 beds. With the 1918-1919 influenza epidemic which is pretty similar in many ways to this, 30% of people got sick before it was over, in our town that would be somewhat over 6000 people. I'm not going to belabor the numbers. Just saying... that is <b>way more patients than we can handle</b>. Also, they tend to stay sick for a long time, so the first 25 might fill up the hospital and then there's no room at the inn! Death rates may be as high as 5%, but I imagine it would be worse if there was no way to care for them at the hospital. Those of you who live in a small town might say "what about going to the larger hospital in the next big city?" Nope. They will be full too. </div>
<div>
<br /></div>
<div>
The increase in cases will slow and then stop eventually because people get immune and stop passing it on to others, but that takes awhile. I have drawn a little graph to explain it in a general way.</div>
<div>
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrXbSC5H_AmqtEQ0RD7bvrDoFmw4XoE7IC78adKTPd3qWaizeOC0afvkkBeyaRP2lz0KcSvae6lbJ_TYvSWrTAfA_1cTYglomICp6uFmXy7UrxBH6H51CmFW79pH0HqBss3EhArgdepxw/s1600/IMG_2627.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrXbSC5H_AmqtEQ0RD7bvrDoFmw4XoE7IC78adKTPd3qWaizeOC0afvkkBeyaRP2lz0KcSvae6lbJ_TYvSWrTAfA_1cTYglomICp6uFmXy7UrxBH6H51CmFW79pH0HqBss3EhArgdepxw/s640/IMG_2627.JPG" width="640" /></a></div>
<div>
So that's why the people who are not taking this seriously are wrong. We are on this curve and we can flatten it if we do the stuff we're supposed to but we can't get off of it. Flattening of the curve means that the numbers of patients increase more slowly. It will then take longer to reach the peak number of patients, but we will be less overwhelmed and will be able to care for them better. That scenario is most likely in places that are less densely populated. In our small rural town it may be possible as well as in certain agricultural areas or states. Let me be quite clear: <b>if we socially distance ourselves and practice excellent hygiene and infection control, fewer people will get sick and things will not look so bad.</b></div>
<div>
<br /></div>
<div>
Some people who follow the news ask why China has had so few cases. The population of China is nearly 2 billion people. The explanation I have heard is that the virus was almost entirely contained in Hubei Province and, within that, the city Wuhan. There was no travel allowed out of Hubei Province and within the city of Wuhan and the province there was extensive testing and strictly enforced social distancing. According to news, there have been no new cases in China for two days now after an epidemic that started around the beginning of the year. The province of Hubei has 58 million people and the city of Wuhan 11 million, and with a total of around 80,000 cases in all of China, far fewer than 30% of people were infected. Their strategy clearly worked pretty well. Unfortunately very few people in China are immune and it is a crowded country with significant poverty. When the coronavirus is either re-imported or some infected toddler without any symptoms transmits it to his many little friends and their parents and grandparents the whole epidemic could be rekindled. Nobody really knows what will happen in the next year. When a vaccine becomes available all of this will improve tremendously.<br />
<br />
More on exponential growth and epidemics:<br />
<br />
<span style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;">There are some really good explanations on YouTube:</span><br style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;" /><span style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;">For the nerdy: <a href="https://www.youtube.com/watch?v=Kas0tIxDvrg" target="_blank">this</a></span><br style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;" /><br style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;" /><span style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;">For regular people: <a href="https://www.youtube.com/watch?v=fgBla7RepXU" target="_blank">this</a></span><br style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;" /><br style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;" /><span style="background-color: white; color: #292929; font-family: Lora, serif; font-size: 16px;">For people who love Harry Potter and are ready for an exponential growth metaphor: <a href="https://www.youtube.com/watch?v=mcMjdSk9EfY" target="_blank">this</a></span></div>
Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com1tag:blogger.com,1999:blog-1350181109033523476.post-4592306299755498502020-03-19T19:28:00.000-07:002020-03-19T19:28:09.386-07:00Covid19--can we really just drop everything? #mycoviddiary<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgROpHdO-O6Rv2RSgrRmEhJEwS4vR13I2BfizMh94kZp7aRJhvO9BHJJTrEsxuDx3ewmEJedT3_H3kL5zkQjmQkma746ppY5DpRXcNlH0VMqJeouY30M1igzyPjuM4I3DG9GdmI0_BJwPs/s1600/IMG_2607.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgROpHdO-O6Rv2RSgrRmEhJEwS4vR13I2BfizMh94kZp7aRJhvO9BHJJTrEsxuDx3ewmEJedT3_H3kL5zkQjmQkma746ppY5DpRXcNlH0VMqJeouY30M1igzyPjuM4I3DG9GdmI0_BJwPs/s320/IMG_2607.JPG" width="240" /></a></div>
Still vigorously healthy, thank you. I sneezed once yesterday afternoon and my voice was just a wee bit gravelly. Today my nose runs when I'm out in the cold. It always does that. No exposures that I'm aware of.<br />
<br />
My clinic is functioning as well as it can, consistent with keeping almost everyone out of our waiting room. We have agreed to keep meetings to no more than 10 people with everyone at least 6 feet apart. We have all been instructed to self screen every morning for new significant cough, sore throat, shortness of breath or fever over 100. Most of my patients have been phone visits rather than in person but I saw a few. I do a better job in person, but spending a good amount of time with someone on the phone is not without its benefits. The counselors and psychiatric nurse practitioners will be working from home until this is over. They had one day to figure out how to do this. Their patients are kind of reeling. Nobody had typical coronavirus symptoms. Things are kind of slow right now.<br />
<br />
<b>Thoughts:</b><br />
<b>One good thing:</b> Our patients at the clinic where I work are often grindingly poor. No insurance, no income, burned bridges everywhere. I have no idea how they afford the cheap hotel room where they sleep or any food at all. The government--not just Andrew Wang or Bernie Sanders, but even conservatives--are talking about giving all US citizens a check for maybe $2000 as an economic stimulus. This would be amazing for our patients. It would make all the difference in the world. And not just because of coronavirus. They could fill up the tank of the car that they call home, buy shoes, maybe pay a bill or two. There are patients for whom the safety net provides no safety at all.<br />
<b><br /></b>
<b>A few bad things: </b><br />
<br />
<ul>
<li>"Thank god we have our phones." The internet is becoming the source of all joy. AARRGH! Yay Zoom conferences. Computer games. YouTube videos. Endless memes. I don't recall saying this was OK.</li>
<li>Unintended pregnancy: people talk about how they wish they'd gotten a haircut before all of these businesses closed their doors. What about an IUD or other long term birth control device? All this being cooped up with ones near and dear ones with nothing to do will lead to little unintended bundles of joy. I see so clearly in the office how much of being unhappy comes from having been born to a family that didn't really want or need a baby. Family planning is a gift. I wish we'd gotten more birth control done before we went to telephone visits!</li>
<li>Xenophobia=fear of the other: We're mad at all the countries that caused us to have an epidemic by having as little foresight as we do now. Everybody else shoulda known. We were getting more adversarial with other countries before this happened which is part of why this whole epidemic mess was not contained to a few areas. Finger pointing seems to be one of our most entertaining hobbies. Really understanding our shared humanity is one of the most effective ways to prevent war. </li>
</ul>
<div>
It's weird to be a doctor who isn't busy, in a time when globally my skills are needed. If I were a plane I'd be in a holding pattern.</div>
<div>
<br /></div>
<div>
<br /></div>
<div>
<br /></div>
Janice Boughtonhttp://www.blogger.com/profile/02321947802871503562noreply@blogger.com1