Archive for the ‘Medicine’ Category

Author’s note: This article was written in late March, 2020, for publication in the American Society of Anesthesiologists’ monthly magazine, the ASA Monitor. It was published online ahead of print on May 8, 2020.

As you read this, we will be at least six weeks further down the road of the COVID-19 pandemic than we are today. We may have answers to the questions that are causing us sleepless nights. With the benefit of that hindsight, what should we have done differently if we had known in March what we know today, in May?

There are two ways to look at this: the “macro” view and the “micro” view. The first refers to national policy, and the second looks at what we are doing as physicians, in our own hospitals. Let’s start with “micro”, as that’s what we have the most ability (perhaps) to influence.

Did we get serious about personal protective equipment (PPE) too early or too late? Did we waste it on asymptomatic, healthy patients before the pandemic really got started? Or did we fail to take it seriously enough, endangering ourselves, colleagues, and patients?

As I write, some hospitals are still working under a policy of using standard droplet precautions (regular surgical masks and eye protection) for asymptomatic patients, though guidelines are evolving rapidly with recognition that intubation and extubation are aerosol-generating procedures that warrant N95 mask protection. For hospitals with supplies of N95 masks that will only last a few more days, this is a looming problem, not easily solved. Manufacturers can’t meet even the current demand, and at least here in Los Angeles, the surge hasn’t peaked.

Other hospitals have already moved to using enhanced PPE for routine intubation and extubation in asymptomatic patients: for example, otherwise healthy patients presenting for breast cancer surgery. This practice is based on the fear that asymptomatic patients may be coronavirus carriers. Depending on the aggressiveness of the anesthesiology leadership, the recommended precautions may include head-to-toe coverage – what Atul Gawande, MD, MPH, referred to, in his March 21 New Yorker article on protecting healthcare workers, as “full Wuhan”. Will they regret this later, if supplies are exhausted? Was this ethically the right call when so many other hospitals lack basic supplies? Will they incur hostility from ICU or ED staff who arguably need enhanced PPE more urgently for critically ill patients? Or will they be very glad they did because their personnel escaped COVID-19 infection altogether? We just don’t know.

Dr. Gawande concluded that coronavirus transmission “seems to occur primarily through sustained exposure in the absence of basic protection or through the lack of hand hygiene after contact with secretions.” In other words, wash your hands and don’t touch your face. The best PPE in the world won’t help you if you contaminate your hands while taking it off, and then touch your face without washing your hands. He believes the “standard public-health playbook” can still manage this epidemic:  basic hand hygiene and cleaning; targeted isolation and quarantine of the ill.

Perhaps by May, all personnel in every hospital will be wearing standard surgical masks for patient interactions, as the best way to protect us all from droplet transmission by coughing. That seems sensible, but again, we don’t know if we’ll have enough masks. Perhaps by May, the enduring standard of care will be always to use N95 masks and tight-fitting goggles for intubation and extubation, even after the worst of the COVID-19 surge has ebbed. We’ll see.

The “macro” view

There are so many questions, and so few answers.

Was it the right call to close schools? Did this help to reduce coronavirus transmission? Or did it slow the rate of acquiring herd immunity among children, the population least likely to develop serious COVID-19 complications? Michael Osterholm, MD, MPH, a public health and infectious disease expert, argued in the Washington Post on March 21 that there has been no real difference in the rate of transmission between Hong Kong, where schools closed, and Singapore, where they didn’t. Meanwhile, the stress on the healthcare workforce is worse because of childcare worries on top of all else.

Chandra Ellis, MD, a plastic surgeon and burn expert, says she is seeing new cases of small children with burn injuries suffered at home from hot coffee spills and open oven doors, and she believes there will be more. Parents trying to work from home aren’t used to watching active toddlers at the same time. Is working from home really the best approach, or would healthy parents be better off at work with their work stations further apart, consistent handwashing, and support for generous sick leave policies so that they can stay home if they’re ill?

Why are some young, previously healthy adults ending up on ventilators from inflammatory complications of coronavirus? Could the severity of COVID-19 illness correlate with peanut allergy and asthma, which are more common in younger adults, or with vaping?

We understand – or think we do – why older patients are more susceptible to severe COVID-19 illness:  their immune systems aren’t as robust, and they have more underlying diseases. Does the severity of disease in older patients correlate (or not) with taking angiotensin-receptor blockers, whose biology has complex interactions with COVID-19?

What about East Asian patients who have a facial-flushing reaction to alcohol intake – do they survive COVID-19 better than others? We’ve never completely understood why there is a 30-50 percent frequency of the ALDH2*2 (acetaldehyde dehydrogenase) allele in East Asian populations (Chang, 2017). That allele is known to raise the risk of certain cancers (esophageal, stomach), but could it also confer resistance to zoonotic coronaviruses, which may have been a recurring source of viral illness in Asia for centuries?

How long can the lockdown last before the economic consequences become so severe that the public mutinies? Will “speakeasy” restaurants and hair salons start to open surreptitiously? It’s obvious that the economic hardships are greatest among the lowest-paid workers – restaurant employees, hotel cleaners, ride-share drivers. Will we see families lining up at food banks as they did in the breadlines of the Great Depression?

While major medical centers may be swamped with patients, and some anesthesiologists find themselves pulled from the OR to serve as intensive care physicians, ambulatory surgery centers aren’t calling in their usual per diem anesthesiologists to do cases. Many anesthesiologists aren’t working at all as elective cases dry up. All of us are seeing a horrifying drop in the value of our retirement portfolios. What will the economic outcome be for our profession as a whole?

Probably the most important remaining question is the one posed by Neil Ferguson, MA, DPhil, and his colleagues at the Imperial College of London: Can non-pharmacological interventions reduce COVID-19 mortality and healthcare demand? The authors believe that intensive intervention – social isolation, business shutdown – would have to continue until a vaccine is developed, which could be as long as 18 months away (Ferguson, 2020). We think these measures work, judging from the experiences in China, South Korea, and Singapore. It’s too early to tell yet about Italy, Spain, Germany, and England. The curve can be flattened, but what happens if interventions are relaxed? Will case numbers rebound? The authors conclude:

“While experience in China and now South Korea shows that suppression is possible in the short term, it remains to be seen whether it is possible long-term, and whether the social and economic costs of the interventions adopted thus far can be reduced.”

Dr. Ferguson tested positive for COVID-19 on March 18. Will he survive? What about U.S. Senator Rand Paul, who also has tested positive? Will COVID-19 go on to decimate the highest echelons of government worldwide? Will we conclude after the fact that America relaxed our own restrictions too early or too late?

As the great Danish physicist Niels Bohr said, “it is very difficult to predict – especially the future.” Will the month of May bring warmer weather, reduced viral activity, and a return to normal? Or will the new normal be worse than it is today? Right now, in March, no one knows.

Do you think I went too far in my last blog post, calling out some journalists as “pontificating parasites” who love nothing more than to slam physicians and blame us for the cost of healthcare?

If you do, then you must not have read Elisabeth Rosenthal’s latest salvo in the Feb. 16 New York Times, where she says physicians are in “a three-way competition for your money” with hospitals and insurers, as if we’re all equally well-funded players at a craps table.

Even National Public Radio, often no friend to physicians, acknowledges that physician pay adds up to a mere eight percent of total US healthcare costs.

What stings even more, hearing that kind of accusation from Ms. Rosenthal, is that she used to be a physician herself before she quit emergency medicine to edit Kaiser Health News. I’m sure it’s a better gig: no nights, no weekends, no holidays. But, as Julius Caesar noted, it’s always worse when the stab in the back comes from someone you thought of as a colleague, if not a friend.

Surprise medical bills

The topic of Ms. Rosenthal’s one-sided op-ed is out-of-network billing, also known as “surprise” billing. Emergency physicians (along with anesthesiologists) may be the doctors most often accused of not being “in-network” with insurance companies and sending patients large “surprise” bills after the fact.

However, the American College of Emergency Physicians (ACEP), which represents Ms. Rosenthal’s former colleagues, is no happier than anyone else about out-of-network bills. “Much of this conflict over surprise billing is playing out in the media,” ACEP notes, “and insurers have been trying their hardest to paint emergency physicians in a bad light.”

ACEP is right. The facts about out-of-network bills, and the history behind them, differ from what Ms. Rosenthal would have the public believe.

What is a narrow network?

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If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

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“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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The Hahnemann Disaster

Though the news at first stayed local in Philadelphia and the northeast, it’s gaining traction nationwide. ZDoggMD is on it. Bernie Sanders held a rally.

What happened? The venerable Hahnemann University Hospital, the main teaching hospital for Drexel University College of Medicine in Philadelphia, is bankrupt and will soon close its doors after more than 170 years as a safety-net hospital serving inner city patients.

Why should we care? After all, there are other teaching hospitals in the immediate area with capacity to absorb the patients, and they had several months’ warning to prepare.

We should care for many reasons, but I’ll start with the plight of the 570 residents and fellows who are being displaced from their jobs. Getting a residency position in the first place is a perilous process – there aren’t enough spots for all the graduating medical students who want them. Only 79% of the more than 38,000 applicants in 2019 snagged a first-year or internship position in a residency program.

So the Hahnemann residents – the “Orphans from HUH”, as they’ve started to call themselves – are scrambling on their own to find new jobs at a time when most residents are thankfully settling in to the new academic year. There’s no organized program to help them.

Even for the residents who’ve already found new positions, there are other boulders in the road. To begin with, they haven’t been released yet. They can’t start their new jobs and the Medicare funding for their positions is still tied up in bankruptcy court.

They’re still at work, wandering around a nearly empty Hahnemann with only a handful of patients left. The ER isn’t admitting any new patients and will shut down completely on August 16. The labor-and-delivery ward has closed. The new interns aren’t gaining any real experience and will be lagging behind their peers wherever they go.

“Doctors have been writing notes to update plans of care and people have come in as part of the liquidation to take away their computers,” a third-year internal medicine resident named Tom Sibert, MD, told Medscape reporter Marcia Frelick last week.

Tom Sibert? Any relation? Why yes; he’s my son. You can understand, I’m sure, why I went into full-blown mama lion fury when the Hahnemann situation blew up, and why I was beside myself with worry until he locked in an acceptance to an excellent program where he’ll finish his training.

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