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About Catherine Cheng, MD

I am a general internist in Chicago, Illinois, mother of two, almost native Coloradan, and Northwestern alum. I want to leave the world better for my having lived, by cultivating the best possible relationships between all who know me, and all whom I influence. Join me on this crazy, idealistic, fascinating journey! Look for new posts on the 10th, 20th, and 30th of each month. Opinions posted here are entirely my own, and in no way reflect the opinions or policies of my employer.

Please Stop With the Fighting

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What a difference a week makes.  How are you feeling?  I can only describe my own experience as ‘off.’  Things feel heavy, fraught, tense, uncertain, and anxious.  All the talking and writing I do about tolerating uncertainty and holding space for tension feels almost comically hypocritical right now, as I grapple with my own practices.  But more than that, I feel accelerated degradation of relationships all around me.  Armed men march and yell at the Michigan capitol building (where a woman governor serves).  More armed men gather in front of state public health director Dr. Amy Acton’s house in Ohio (not the capitol, where a man governor serves), saying there will be no violence, “for now.”

People on the ‘side’ of public health deride decisions to reopen state economies as willfully ignorant, even malicious.  People on the ‘side’ of reopening economies derail stay at home orders as fascist.  Perhaps these are the minority voices of each ‘side’, but they are loud, and they dominate public discourse and social media (I know, I know, moderate my intake, yada yada).  Yet another false dichotomy escalates with increasing vehemence on both sides.  I have mulled it for weeks and not found a good way to write about it.

Late yesterday, I found two pieces that help, written by conservatives I respect.

In the first, “What Republicans’ Kool Aid Moment Means for the Rest of Us”, Chris Ladd outlines our fatal flaw as humans, and then asks some profoundly important questions about how to resist the ultimate pitfalls of that flaw:

“Confronted with displays of cult loyalty we commonly resort to some mistaken conclusions, dismissing these people as crazy or stupid. These assumptions are born of the same logic that leads people to blame the sick for their illness, a desire to manufacture some difference between them and us, something that would leave us immune to their condition. We want to believe that there’s something uniquely broken, inferior, or even subhuman about the people in those pathetically sad images of self-destruction. Those dismissive characterizations of cultists aren’t just false, they are dangerous.

“We are not inherently rational creatures. By nature, our model of reality is not a product of careful individual inquiry, formed through a critical review of all available data, but a social construct heavily influenced by our preferences, hopes, and the collective will of our tribe. Human beings are capable of independent, rational thought premised on a body of constantly moving data, just like we are capable of juggling or riding a bike. Absent special training, critical, data-centered reasoning is so effortful, difficult and unnatural that any political order premised on the rationality of the average man will be consistently unstable.

“Even with careful training over years, a life of critical thought remains a challenging endeavor, costly to maintain and not suited to every circumstance. Riding a bike sounds easy once you’ve learned to do it but try dialing your phone or eating a sandwich while peddling and you’ll see the challenge. Careful, critical reasoning is resource-expensive. None of us engage in it as much as we think we do.

* * * * *

In the second essay, “What If We Loved Them Both?”  David French invites us to exercise that resource-expensive skill of critical, rational, nuanced and complex analysis:

“Once again, our nation is faced with the painful process of sorting through grave sexual assault allegations against a powerful man. Once again, the public assessment of the veracity of those claims is lining up all-too-neatly with the partisan needs of the moment. Those who object to the rush to judgment against the accused will often ask if how we’d respond if, say, Joe Biden or Brett Kavanaugh was someone you loved. What if he was your father or grandfather. Would you feel like they’d been treated fairly?

“The counter is quick. What if Tara Reade or Christine Blasey Ford was someone you loved? Can you imagine how you’d feel as they mustered up the courage to tell a dreadful story and then you watched them endure the inevitable slings and arrows of scorn, hatred, and mockery?

“But there’s a different, better construct. What would the world look like if an imperfect population that possessed imperfect knowledge loved them both?  

“Due process is just, and it’s indispensable to the pursuit of justice. It is the answer to the question at the start of this newsletter—in the most fraught of claims and the most vicious of crimes—What if we loved them both? What if both accused and accuser were of equal worth? When we consider the right to bring a claim, the requirements of evidence, and even the time limits imposed on cases (given the difficulty of both defending against and proving very old allegations), we not only humbly acknowledge our inability to peer into a person’s soul to discern truth, we also acknowledge that even the mightiest man can and should be brought low when the evidence dictates. 

“But protecting due process (like protecting free speech) is hard. Just as permitting bad speech is a necessity for maintaining the larger, just legal structure of free speech—individual injustices can also protect the larger, necessary structure of due process.

“Each person involved in the controversy is of equal worth, a human being created in God’s image. That means the accusers have a right to bring their claim and be heard, respectfully and fully. That means the accused have their own rights to defend themselves, and a presumption of innocence is wise. Our own extreme fallibility and inability to peer into a human soul means that we should diligently seek external evidence that corroborates or rebuts any allegation or defense. 

“It is true that our culture has frequently failed women. It has failed in the obligation to treat them with respect or to fully hear or fairly consider their claims of terrible crimes. It is also true that our culture has also failed men, especially black men. There are simply too many terribly tragic tales of men dying at the hands of a mob in the face of an unsubstantiated claim of sexual misconduct. Even today, there are echoes of that awful injustice in the way in which black men are treated in campus courts. 

“But the answer to historical injustice isn’t another, equal and opposite injustice. That’s the score-settling that leads to endless ideological and partisan conflict. Instead, the answer is to discern the correct standard, and hew to it as closely as we can. Conservatives should not seek ‘revenge’ for Brett Kavanaugh. Progressives should not give in to the temptation of believing a Democrat through highly-subjective judgments of ‘demeanor’ or ‘temperament.’ That’s the God’s-eye view. And human beings are terrible at playing God.” 

* * * * *

The essays above, while encouraging, also ring abstract and esoteric.  How do we take these lofty ideals and apply them today, in our daily lives, so as not to feel so disconnected, so disparate?  Because what good are ideals if we cannot live them out?  We really are all in this together.  What’s helping you remember that, really feel it, right now?

In our lifetime, there may be no more important moment than right now to recognize and truly honor, in our minds, hearts, and bodies, our shared humanity.  I took a stab at an action plan with the list below.  What would you add?

  1. Stop thinking ‘we’ are better than ‘them’; really try hard to see everybody as equally worthy to engage.
  2. Marshal our best skills at patience and generosity when ‘they’ say they’re better than ‘us.’
  3. Focus on shared goals and humanity— how are we all ‘us’?
  4. Lead by example resisting the urge to oversimplify and over generalize; look for and point out complexity and nuance.  See this as a strength rather than a weakness.
  5. Do not fall for baiting and inciting statements meant to trigger defensiveness.
  6. Acknowledge and concede the flaws and faults of ‘our side’; encourage others to do the same.
  7. Disengage, for the moment, when ‘opponents’ as well as ‘allies’ show themselves, or we find ourselves, to be uninterested in following or unable to follow these rules of engagement. Even when our intentions are earnest, this stuff is hard. And it takes grit and perseverance to train. And almost all of us are total novices at it. So we have a LONG way to go. Try again later. And again, and again, and again.

 

A Time to Try New Things

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My friends:  What’s happening for you these many weeks?  What are you noticing (again, still, and newly)?  What do you miss most, least, and/or not at all from pre-COVID life?

What’s been the best thing that’s happened for you in this time?

Many of us are out of our depth here; we have no map.  As NASA says, we must “test as we fly and fly as we test.”  That necessarily means putting aside what we usually do and how things usually work, and trying new things–experimenting.  What a fantastic opportunity for learning, growth, and connection!

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The Alphabet Workout

How has the pandemic affected your physical activity?  How have you adjusted?  After the New Year I realized I needed workout buddies to strengthen my workout resolve.  My colleague and I started exercising together after work a couple days a week, and then the pandemic hit.  Almost right away I came across various alphabet-based interval workouts, perfect for the newly shut in.  My siblings and friends and I started meeting on Zoom to try it, first spelling our names.  We moved on quickly to our heroes’ names, and now to sayings we like.  Exercise, accountability, variety, fun, and connection—yay!

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Baking

My daughter may single-handedly make our whole family diabetic.

Spring break started a week early, then the kids transitioned to distance learning, with minimal direct, real time interaction with teachers.  With so much more time to complete homework and a recently developed fascination with any and all things French, we now have a baker in the house.  And with anaphylactic allergies in the family, recipes are necessarily converted to vegan and nut-free.  To date she has succeeded with macarons, beignets, fruit turnovers, cupcakes, and red velvet cake.  But by far I’m proudest of her opera cake, completed tonight and surely damaging to my waistline.  It’s worth it, though, to watch her experiment, fail, redirect, and succeed (mantra = “It’s edible!”), gaining confidence with every attempt.

The sibs had better not abandon me on those Zoom workouts, though!

moon path LOH

Photo courtesy of Dr. Karen Cornell, January 2020, Loveland, CO

Circadian Loosening

I always knew I was a night owl, but holy cow, left to my own devices, I am practically nocturnal.  I never pulled all-nighters for school.  The first time I stayed up all night reading was for one of Rick Riordan’s Percy Jackson books—I had not even done that for Harry Potter!  I have discipline when I need it.  I get up for morning calls now; I even look forward to them, as a sailor looks for the buoy thrown by his shipmates when he has fallen overboard.  I will readjust to a regular work schedule when the time comes.  But for now I can truly enjoy my owl self.

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Connecting with Friends

Maybe you’re missing your friends the most.  Somehow I’m not, which is a bit shocking and disconcerting.  But maybe it’s because I’m still connected, in some cases better than ever.  I miss meeting Donna for breakfast at our usual egg and toast place.  But I love that we now talk weekly on the phone while walking outside.  I continue to send and receive snail mail from friends across the country.  Perhaps I’m FaceTiming more with the Colorado sister and my parents, in addition to our sibs Zoom workouts.  And finally yesterday, blogging friends Nancy and Donna and I got together, after talking about it for at least three years.  Of course it was over Zoom, but without COVID-19 who knows how long it would have taken us to meet in person, living in Washington, Illinois, and Michigan?  Now we plan to ‘meet’ monthly—so much to share!

Writing Out of My Comfort Zone

Thanks to sister member Christina Guthier from Ozan Varol’s Inner Circle, I accepted a 5 day mindful writing challenge set by Nadia Colburn this past week.  Free, only five days—why not?  Nancy, Anne, and a few other friends agreed to try it with me—they accepted my Facebook invitation.  After a short meditation and poem, each day Nadia offered a prompt, followed by ten minutes of writing dotted with serene reminders to stay with the breath and remember to smile.  In these brief, structured and yet freeform sessions, I stretched existing ideas and queries farther than usual.  I quieted the inner critic sometimes and not others.  I learned a little more about my style and preferences for writing.  And I wrote a poem.

Based on “I Am Offering This Poem” by Jimmy Santiago Baca, Day 5’s prompt asked us to write a poem entitled, “I Am Offering This ______ to You.”

Onward, my friends.  Let us try new things, learn, grow and connect.

 

I Am Offering This Love to You

So imperfect

So flawed

So human

Yet honest, earnest, real

How can I make sure

You feel it the way I intend?

Or do I even need to?

Who would that be for?

What’s the best way for you to feel

Loved by me?

According to whom?

What is the best outcome

Of all this love

We carry for each other

In our families

Between friends

For our country

For the world

For humanity?

How can we live into this now

Today?

I am offering this Love to you

Now

On this day

In this moment

With this breath

What will you do with it?

COVID-19 Antibody Testing: What We (Think We) Know and Don’t Know

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Friends, my practice has sent this letter to our patients.  It is a summary of what we think we know about COVID-19 antibody testing, as of today.  This is our collective opinion and expression as a practice.  We do not speak for our employer or colleagues at large.  It is our best interpretation of the available evidence to date, and we present it in good faith.  Information evolves rapidly, and we expect to update our position and practices accordingly.  Please vet your information sources well, and make any and all medical decisions in collaboration with your primary care physician.

Many states are likely to extend shelter in place orders, albeit with some slow loosening of restrictions.  I worry that this will incite further unrest and divisions along ideological lines.

We all must now call forth our highest practices of patience, generosity, and love, so as to pull together better rather than separate further in body, mind, and spirit.  Hang in there, my peeps.  We can do this.

* * * * *

COVID-19 Antibody Testing

Covid-19 antibody testing is being promoted as a way to tell who has already had COVID-19 and therefore may be immune. We are getting many inquiries about the availability of antibody testing and wanted to let you know about the current state of antibody testing.

If you have had COVID-19, are you immune to it?

We don’t know the answer to this.  What we do know:

  • Most other viral infections stimulate your body to make antibodies against the virus which provide some degree of protection from re-infection for some period of time.
  • Antibodies to the common cold, which is sometimes caused by another type of coronavirus, seem to last only 1-3 years. Antibodies to measles generally last a lifetime.
  • There have been a few reports of seeming re-infections with COVID-19 in China and South Korea, but this is thought to more likely be due to a testing problem rather than true re-infection.
  • It’s very likely that people who have had COVID-19 should have some immunity for some period of time, but nobody knows for sure.

Does the severity of COVID-19 illness or the levels of antibody matter for presumed immunity?

When you are infected with a virus, your body makes many different types of antibodies against many different parts of the virus, in differing quantities. The IgG class of antibodies is the one that tends to provide long term immunity. Scientists are currently looking at all of the different antibodies present in the plasma of people who have had COVID-19, to see which antibodies seem to be the most numerous and react most strongly against the virus.

We currently don’t know which antibodies are most protective, how many of the different antibodies you need to have to be protected, or whether the levels of the antibodies matter for either degree or longevity of protection.

What do we need to know about a test before we call it a good test?

After the onset of the pandemic, the FDA allowed institutions and companies produce their own tests, provided they used an FDA-approved procedure to validate the tests. It’s not at all difficult to make an antibody test . . .but it’s very difficult to make a GOOD antibody test. You have to know:

  • Which antibodies to look for
  • How many antibodies to look for
  • What it means if some antibodies are present but not others (what if 2 of 4 tested antibodies are found -does that mean you are immune?)
  • How good your test is at picking up the people who have a positive test and are truly immune (the positive predictive value of the test)
  • If your test correctly tests negative when people have NOT been infected (the negative predictive value)
  • If your test is specific to COVID-19, or if it shows a positive result by detecting antibodies from infection with a different virus in the last few years (many common colds are caused by other types of coronaviruses).
  • That your test is valid -meaning you have reliably answered the questions above in as many people as possible. Generally this requires hundreds of people known to be positive and negative, as well as some who had other upper respiratory illnesses.

Finally, it is VERY important to remember what we DON’T KNOW:

  • Whether having antibodies and which type of antibodies actually provide immunity
  • If it does, how long the immunity lasts
  • If you have antibodies and have a new virus exposure, whether reinfection can occur
  • If you have antibodies and have a new virus exposure, whether you could still potentially transmit it to non-infected people

If scientists are still studying the antibodies, why are there hundreds of antibody tests already on the market and one being done by a drive-through facility in Chicago?

Many of the tests currently on the market are imported from China or Europe, and some have been made by small US companies who have rushed to produce a test (again, it’s easy to make any test; hard to make a good one).

We have investigated a number of these tests to see how they have been validated and how reliable they are, and the answer is that all of these tests are remarkably poor. (For those who want the scientific details, see below.)

NONE OF THESE TESTS HAVE BEEN VALIDATED OR APPROVED BY ANYONE OTHER THAN THE PEOPLE WHO  MADE THEM, AND THEY CAN DO ANY KIND OF TESTING THEY WANT, WHICH IS LARGELY GROSSLY INADEQUATE.

OK, so if what’s available now is terrible, will there be good antibody tests, and when?

YES! There will be good tests, likely in several weeks. Abbott has a test they are working to validate, as does Roche. When a RELIABLY GOOD, adequately validated antibody test is available to the general public, we will let you know. We anticipate that the first tests will be used to test healthcare and other essential workers, and then as production increases and reliability confirmed, extended to test the public.

Just a reminder . . .

Continue to wash your hands well and frequently, especially if you have been out in public.

Continue to stay 6 feet away from anyone if you leave your house.

We recommend wearing a mask if you are out in public. Remember that the mask protects others from you, and does not necessarily protect you from others . . .so the 6-feet distancing remains very important!

The nitty gritty scientific details, for those who may be interested . . .

Many of these tests look for antibodies to the coronavirus ‘spike protein’, the part that attaches the virus to human cells. The spike protein is very similar across all coronavirus species, so the risk for false positives is high in people who have had the common cold in the last few years (which is all of us).

The test currently being offered by a drive-through in Chicago is made by a German company, Euroimmun.  A recent paper examining its performance found that its sensitivity (meaning the test both accurately found positive and negatives) was only 67%. Put another way, a full third of people had test results that weren’t accurate. The positive predictive value -meaning if you test positive, the likelihood that you actually had the disease -is only 82% (so 18% of people think they are immune to COVID when they are not), and the negative predictive value is 87%.

Another test that is being marked by Vibrant America for $149, was ‘validated’ in a total of only 20-30 patients, which is far too few to claim reliable test performance. It tests several antibodies, each with a sensitivity of only 65-80%. The company doesn’t say how they interpret  a mixed positive/negative result (indeed no one knows how to interpret this right now). Finally, in the small print, the company notes that their test may be positive in people who had common colds in the past.

4/23/2020 11:10pm CDT–  Updated to add:  Please click/tap to find the formal statement on SARS-CoV-2 antibody testing from the Infectious Diseases Society of America (IDSA).  Bottom line:  There are no reliable tests at this time, and none of them should be used to make individual diagnostic or screening decisions.  Also, answers to myriad questions about antibody response are required for vaccine development and testing, so that will likely take many, many months (I expect closer to 18 months or longer, than the 12-18 we have all heard).