Category Archives: physician

Where Is the Light?

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covid fairy penguins melbourne

Photo by Tobias Baumgaertner, Fairy penguins near Melbourne, Australia

*deep breath*

I always wonder about you, dear reader.  Where does this post find you, since we last connected?  How are you?

It’s a good practice to check in with ourselves regularly.  These nine weeks of sheltering in place have exercised my patience, awareness, and identity, among other things.  What have they done for you?  How are you?

For a couple weeks now I have felt all but overwhelmed by darkness.  Infection and death rates have slowed, but they will continue to accumulate indefinitely.  I worry that we will become inured, calloused, to the human toll.  PPE is still in short supply at hospitals across the country. Thousands of my colleagues continue to risk both their physical as well as mental and emotional lives to care for gravely ill patients.  They leave their families and support networks to become the sole supports for patients alone in the hospital, whose own loved ones may not visit, even in the hour of death.

Mostly I have felt burdened by the fighting.  The shouting, protesting, mean memes, and ad hominem all around me, directed both by and at my friends and colleagues.  Important reflections and insights arose this week that helped me see clearly the internal origins of my distress.  I re-accepted and re-integrated these parts of myself.  I was able to laugh out loud, exclaiming, “How fascinating!”  I know I will necessarily repeat this discovery exercise ad nauseam, ad infinitum—such is life, karma says, also laughing.  But for now I feel lighter, unburdened, more at peace.

So I thought about role models for peace.  I feel so lucky to have so many.  But one in particular shone in my consciousness this week:  Dr. Vivek Murthy, our 19th Surgeon General.  He has published a book, Together, in which he “makes a case for loneliness as a public health concern: a root cause and contributor to many of the epidemics sweeping the world today from alcohol and drug addiction to violence to depression and anxiety. Loneliness, he argues, is affecting not only our health but also how our children experience school, how we perform in the workplace, and the sense of division and polarization in our society.”

I recently watched a live interview with him conducted by Dr. Lucy Kalanithi, widow of Dr. Paul Kalanithi, who wrote When Breath Becomes Air.  I listened with one earbud, watching in my peripheral vision, while hurrying around my kitchen, preparing chicken and assembling a salad, all before rushing to host a Zoom workout.  It struck me that in stark contrast to my frenetic energy at that moment, Dr. Murthy presented only calm and serenity.  He answered every question with love, joy, conviction, and equanimity.  I noticed and marveled.  Then I rushed around some more and got on with my evening tasks.

Looking back, I have felt this serene and loving presence every time he speaks.  He has a way of making everybody in the room comfortable, welcome, and included.  Even if he’s interacting only with a moderator, it feels like he’s speaking to me personally.  He sees me, he gets me.  He cares about me.  In searching for the Kalanithi interview, I came across this lecture and discussion he gave at Stanford University in 2015.  I hope you will take the time to watch (or at least listen).  Notice how he shares stories of his parents, his patients, and people he met during his national ‘listening tour’ at the beginning of his tenure as Surgeon General.  Hear how he sees and knows every one of these people in their whole humanity.  Abraham Verghese, physician, author of Cutting for Stone, and another hero of the profession, moderated the Q&A, and also named Dr. Murthy’s equanimity—his peacefulness.  Notice how Murthy validates questions asked by students and faculty alike.  Observe his humility, juxtaposed with a resolute, unwavering point of view.  Do you feel it?  Does he not inspire you to be a better person?

Dr. Murthy and his wife, Dr. Alice Chen, have written an open letter to us medical professionals, in the midst of this global pandemic.  Reading it, once again I feel seen, understood, and comforted.  I feel true belonging in a proud and humble tribe of professionals, committed to service.  They shine their light on all of us, so we may see the path before us more clearly and walk more confidently, knowing we’ got our peeps holding us up.  This, in turn, gives us the strength and love to hold up others along the way.

I see the light tonight.  It emanates from my fellow and sister humans, and it saves me.

For a little more light, check out this Jon S. Randal Peace Page post with the picture of the penguins.  In it you will read about gems like John Krazinski’s “Some Good News” YouTube series, and Chris LaCass, founder of Pandemic Kitchen, feeding New York City’s homeless.  You can also share your own stories of inspiration and light in the darkness.

Where is your light today?  How will you keep it in front, as we travel this long road together?

 

 

Trust and Safety in an Uncertain World

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Suddenly I felt my heart pounding.  My palms got sweaty.  My jaw felt tense.  I’m anxious, I realized.  It felt like sometimes when I speak up in big meetings.  Wow, I don’t even have to be in front of people for this to happen, how fascinating.

It was the second or third comment I had written on another Facebook page, belonging to a high school classmate.  I think we became ‘friends’ through his wife, a friendly acquaintance of mine in high school, with whom I’ve been connected on Facebook for several years.  I don’t really know her husband at all, and yet here I was, writing long replies on his page about universal masking, why recommendations changed between March and now, and why I trust Dr. Fauci despite his apparent flip-flop on this issue.

I had entered someone else’s house, offering my unsolicited opinions.  Though we have a handful of mutual friends, I had no idea who else would attend this party, and whether I would be welcome.  I wasn’t sure it was safe.

And yet I felt compelled to enter, why?  Perhaps I felt defensive of my professional standard bearer, Dr. Fauci, the father of modern infectious disease and icon of science, medicine, and public health.  He has basically led the research to define and defeat HIV/AIDS since the 1980s.  Through six administrations, he has directed the National Institute of Allergy and Infectious Diseases (NIAID) to successfully manage H1N1, Ebola, and Zika, at home and abroad.  He is one of my heroes.  Likely, I also wanted to absolve myself a little, as I had also recommended against masking in public early on.  I wanted to help some strangers see us, the ‘experts’, as human and fallible, and also earnest and caring, worthy of heeding.

So I obsessed over my comments.  I read and reread before posting.  I edited after posting.  I included the links embedded above, inviting anyone on the thread to hear Dr. Fauci in his own words, in full.  I offered my own mea culpa twice, explaining how academics sometimes fall victim to ivory tower thinking, as we did in this case.  Perhaps this was my attempt at earning back whatever trust people may have lost because we experts contradicted ourselves in such an important and pivotal moment.  I regret this, and I wanted people to know, and then maybe not hold it against me (us).  Would I be crucified?  Or would I crack a door open to hearing what I had to say?  I feel anxious now, just thinking about it again.

My own friends discussed this on my page a few weeks ago, after my post on antibody testing (our recommendations have not changed yet).  Paul, MD PhD and rheumatologist, pointed out, “US experts really blew it initially when it came to masks… All they had to do was consider the possibility that Asian countries might be right and then consider that the risk associated with (masking) was virtually zero.  The first thing experts need to do, when confronted with circumstances that are truly new to them, is admit uncertainty and base recommendations accordingly.”  I’m so lucky to have such honest and direct friends.  I replied that I felt badly for following the ‘expert’ advice like a sheep (which is exactly how others on my acquaintance’s page described followers of universal masking, yikes).  “Lesson learned,” I wrote—but have I really learned it?  David, Paul’s and my classmate who now leads quality and hospitalist programs at his institution, replied, “It’s weird to be here with you (two) bashing experts, since the three of us are by any definition, experts.  But the value of experts is not that they’re always right, but that they have a) a better track record and b) the ability to self-correct.”  Yes, humility is key.

It all makes me wonder, how do we trust someone?  I have conversations every day with patients and non-medical friends and family, educating and advising, and they are appreciative; they trust me.  But we have already established mutually respectful, personal relationships.  What made me think I could go on this unfamiliar man’s social media page, interact with perfect strangers, and have them trust or accept anything I said, when they had already expressed reservations about, if not hostility toward, my ‘tribe’?  Was it my place?

The original post commented on universal masking and referenced Dr. Fauci not in a snarky, pejorative, or aggressive way.  If it had I would have scrolled right by.  Because it was a neutral presentation, I felt it could be safe to enter this house and offer my perspective.  Out of respect for the page owner and his friends, I did my best to present both humbly and objectively, to be informative but not condescending.  I really wanted to put my best online foot forward, to represent my tribe and my profession as well and as trustworthily (it’s a word!), as possible—to connect.  So far I have not been attacked, and a few readers have liked my comments.

In the end, as I have written before, I think it’s about how we show up to one another.  I wrote recently about tribal culture, and how through this crisis, individuals can help our own tribes thrive by modeling a more collaborative rather than competitive mindset, by amplifying our togetherness.  “Who do we want to be on the other side of this crisis?” I asked.  David Logan and colleagues go on in their work to discuss how tribes can effectively interact with other tribes, forming alliances and advancing even greater good together.  They posit that tribes draw closer when their respective members, especially designated leaders (representatives), connect.

We find ourselves now in an existential battle for our lives, literally.  Now is exactly the time to find common ground, step onto it, set up camp, and make decisions from there—to merge tribes.  A friend asked me today, “Who do you want to be now?”

I want to be a connector, I answered.  I will do my best not to contribute to division, polarization, alienation, disconnection, and suffering, through my words or actions.  I will not be perfect.  I will make mistakes.  I will continue to learn and apply.  I will strive to earn and maintain people’s trust.  And I will help make it safe for people to question and challenge, discuss and explore any point of view.  In the face of uncertainty, this is what I can offer.

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).