Adam, the current situation in the hospitals in the Texas Medical Center is that there is generally very inconsistent use of masking. In my experience when I go for a clinic visit, about 33% of the staff (nurse aides, physicians, intake secretaries) wear masks and there is no explanation. It is RARE for patients to wear masks. There are no explanations and no apologies. The message to patients must be extremely confusing. I think that this practice is a huge disservice to patients. Institutions need to have a consistent policy with masking at this late point in the pandemic being rare for the staff. A clear statement of reassurance should be prominently displayed indicating that only the extremely frail and immunocompromised may be at risk of bad outcome from SARS-CoV2 infection.
In addition, the practice of handwashing has entirely disappeared in the clinics I visit, a far better method of reducing contagion. Why do you think that is the case?
I can't help but be struck by the diagram at the beginning of the post. I understand this is only introductory to the article, but from my perspective it is foundational to the patient-doctor relationship.
That patient preference is minimized horrifies me -- both as a patient and as an acupuncturist (~18 years) and RN (newly licensed). I thought it was just me. Then I mentioned it to a patient, and before I could finish my sentence she reacted the same way.
It's clearly a top-down perspective where the physician is above the patient. I understand the value of bringing clinical experience into decision-making. I do it all the time with my own patients. But my entire relationship with the patient is based on understanding that patients are the drivers of their cars, and health care providers are merely map-holders, snack-givers, & co-pilots.
I’ve ended up doing some looking into gabapentinoids for my substance misuse work, and I suspect because they work in an extremely general way by depressing axonal flow across many parts of the brain, there’s no reason at all why they shouldn’t suppress some hyperemesis activity. They are of course addictive so I share possibility that they may be effective for non pregnancy related thermoses and could be used in the short term.
Dr. Cifu, is it possible that you didn’t catch covid from patients in those early days because you simply weren’t susceptible at the time? Perhaps you’d been getting plenty of sleep, eating a good diet, getting moderate exercise, and having a little sun exposure now and then? You don’t mention eye protection (almost nobody does) which suggests to me that perhaps the mask wasn’t really doing the heavy lifting of preventing infection.
If only all people and physicians were as honest as you and had not forced people to mask, perhaps we wouldn’t have such a visceral reaction to the suggestion of it or even being “triggered” just hearing or reading about it in a positive light.
“Even if the opportunity presents itself, we would not be able to because no doctor would accept being randomized to no masking”. I would readily accept being randomized to no masking because I think there is true clinical equipoise here. I am a doctor. Therefore, your statement is false. Burn.
I had exactly the same clinical experience as you did, Adam. I never wore a mask and neither did my patients. I never got covid either. Therefore, using your logic, I have proven that not masking is a wonderful thing.
I love much of what you do, but you are just dead wrong vis-a-vis masking. It is not bioplausible (took Vinay on regarding that long ago) and it makes the entire profession look silly when people say such things.
Do you want to know the definition of insanity? I went to the University of Michigan football game with two of my medical school classmates. One is a family physician practicing at a local medical school. The other is a hospitalist at the University of Michigan. We had 101,000 screaming fans- they were wearing masks.
I honestly think there was a psychological barrier for them. if they were that concerned that they were going to get Covid and that's a legitimate thought at the time they should not have been at the game.
Wearing the mask and that environment was no different than having a rabbits foot in their pocket.
If it made them feel better, psychologically I have no problem with that. But physicians come on we have to make judgments and give patients honest opinions.
As a cardiologist, we often do procedures that the truth be told are no different in outcome than decent medical therapy.
Here is the reality. if you die getting bypass surgery in 2024 that's acceptable and is an act of God. if you get medical therapy and die in 2028 it's because you didn't do the bypass in 2024..
I have discussion with patients all the time. It was different at that ball game.
EBM...do we really know what any drugs or vaccines are doing to our bodies over the long term? No, nada, zilch, nothing...it's all guesswork, assumptions and approximation. Where is the evidence that your body is not being harmed? EBM is nothing but a whisper in the wind. It does not exist. But it is a great marketing tool and that is all modern medicine is about.
I agree with the characterization that most clinical decisions made in a day are done so in the absence of good evidence.
Partly, it’s because not every permutation of every clinical scenario can be properly addressed by an adequately powered RCT.
More importantly, the other Sackett pillars beyond scientific evidence (ie pt preferences, and pt comorbidities) will not be adequately reflected by RCTs even if a study is on-point for the clinical question itself.
So the majority of the time, we have to extrapolate from whatever evidence we do have, onto whichever patient’s particulars we are managing. And we do the best we can with the imperfect evidence we have. C’est La vie.
That’s not a call for nihilism, as we still need to do what we can to help the patient whilst avoiding harm, to the best of our knowledge. But it is a call to refrain from “guideline recommendations” that far overstep what is known. So I think your anecdotes are perfectly fine for your own practice. It’s only when people take such examples and make them into policy, where ire is deserved.
In the case of the doctor who masked and never got covid: in this scenario we aren’t considering potential other harms for example, maybe his anxious patient’s anxiety was worsen due to masked doctor or communication was inhibited resulting in poorer outcomes. In addition, because of our fragmented system, there maybe be some bad outcomes that the doctor never finds about because he doesn’t see that patient again so isn’t aware of longer term results
The best protection from infection is a healthy immune system. That requires a balanced omega-6/3 intake which seems to be rare in the World these days.
Bhutan has an interesting COVID-19 situation; 62,697 cases and 21 deaths. (Case/fatality rate: 2,986/1) The official explanation for the low mortality is that they masked up, vaccinated, and social distanced. https://www.who.int/about/accountability/results/who-results-report-2020-mtr/country-story/2021/bhutan# Unofficially, the citizens of that country do not consume much chicken because they prefer beef imported from India. Typically, ungulates have a much better omega fatty acid profile compared to monogastrics. Here's the problem with chicken. “Poultry meats, in particular chicken, have high rates of consumption globally. Poultry is the most consumed type of meat in the United States (US), with chicken being the most common type of poultry consumed. The amounts of chicken and total poultry consumed in the US have more than tripled over the last six decades… Limited evidence from randomized controlled trials indicates the consumption of lean unprocessed chicken as a primary dietary protein source has either beneficial or neutral effects on body weight and body composition and risk factors for CVD and T2DM. Apparently, zero randomized controlled feeding trials have specifically assessed the effects of consuming processed chicken/poultry on these health outcomes.” https://pubmed.ncbi.nlm.nih.gov/37630747/
"People are eating an increasing number of chickens around the world, a trend that has already led to poultry topping charts as the most-consumed meat. The United States is no exception, and is even leading the charge. Chicken overtook beef as the country’s favorite meat in the 1990s. Now, U.S.-style factory farms — and the many problems associated with them — are spreading to countries around the world." https://sentientmedia.org/meat-consumption-in-the-us/
United states corona virus cases: 111,820,082. Deaths: 1,219,487 (Case/fatality rate: 92/1) Mortality was 32 times greater in the United States than in Bhutan.
Thank you again Dr Cifu for your posts. I love your rigor tempered with humanity and seasoned with experience. Recipe for a valuable clinician.
Clinical experience should generate hypotheses and lead to trials. Doesn’t happen enough for a number of reasons. Pharma chokehold on what gets looked at wouldn’t be much interested in a generic drug effectiveness such as gaba in a “ suspect” population of pot users.
Similar to the use of prophylactic doxycycline for tick bites.
When I as a 35 year career as an oncology pharmacist was consulted on novel or off the grid treatment I would ask myself and discuss with the oncologist the downside risk in light of the patients current circumstances. If the risk of harm was acceptable and potential benefit was reasonable I would approve. Something my by the book younger colleagues were not always eager to do.
I would like to see Dr Prasad et al look at the data and literature for doxy prophylaxis in tick bites. It’s a terrifying downside risk for an almost harmless one time dose but does it stand up to scrutiny?
Here in Gloucester MA it’s not an insignificant risk
I'd love to see that study too. I'm in the Niagara region and ticks and lyme disease are becoming an issue here too. Public health has put up billboards showing the different kinds of ticks.
What if....respiratory viruses aren't spread through inhalation but as fomites? That is a trial I would like to see!!
Why is it that nobody ever mentions the characteristic Covid diarrhea that all the patient s had? Honestly, "science" may have been barking up the wrong tree all this time.
I'm not in the mood to go link hunting- help yourself- but I remember plenty of fomite studies during covid, which is why the "leave your groceries in your garage for 2 days and only approach in a class 3 suit" advice went away quietly.
Adam, the current situation in the hospitals in the Texas Medical Center is that there is generally very inconsistent use of masking. In my experience when I go for a clinic visit, about 33% of the staff (nurse aides, physicians, intake secretaries) wear masks and there is no explanation. It is RARE for patients to wear masks. There are no explanations and no apologies. The message to patients must be extremely confusing. I think that this practice is a huge disservice to patients. Institutions need to have a consistent policy with masking at this late point in the pandemic being rare for the staff. A clear statement of reassurance should be prominently displayed indicating that only the extremely frail and immunocompromised may be at risk of bad outcome from SARS-CoV2 infection.
In addition, the practice of handwashing has entirely disappeared in the clinics I visit, a far better method of reducing contagion. Why do you think that is the case?
I can't help but be struck by the diagram at the beginning of the post. I understand this is only introductory to the article, but from my perspective it is foundational to the patient-doctor relationship.
That patient preference is minimized horrifies me -- both as a patient and as an acupuncturist (~18 years) and RN (newly licensed). I thought it was just me. Then I mentioned it to a patient, and before I could finish my sentence she reacted the same way.
It's clearly a top-down perspective where the physician is above the patient. I understand the value of bringing clinical experience into decision-making. I do it all the time with my own patients. But my entire relationship with the patient is based on understanding that patients are the drivers of their cars, and health care providers are merely map-holders, snack-givers, & co-pilots.
YES!
Re: your last paragraph
After only one visit I fired my new primary rather than try to educate/reeducate him.
In my recent post about diagnosis and prognosis, I compare medicine to astrology, with major caveats.
I’ve ended up doing some looking into gabapentinoids for my substance misuse work, and I suspect because they work in an extremely general way by depressing axonal flow across many parts of the brain, there’s no reason at all why they shouldn’t suppress some hyperemesis activity. They are of course addictive so I share possibility that they may be effective for non pregnancy related thermoses and could be used in the short term.
Dr. Cifu, is it possible that you didn’t catch covid from patients in those early days because you simply weren’t susceptible at the time? Perhaps you’d been getting plenty of sleep, eating a good diet, getting moderate exercise, and having a little sun exposure now and then? You don’t mention eye protection (almost nobody does) which suggests to me that perhaps the mask wasn’t really doing the heavy lifting of preventing infection.
If only all people and physicians were as honest as you and had not forced people to mask, perhaps we wouldn’t have such a visceral reaction to the suggestion of it or even being “triggered” just hearing or reading about it in a positive light.
“Even if the opportunity presents itself, we would not be able to because no doctor would accept being randomized to no masking”. I would readily accept being randomized to no masking because I think there is true clinical equipoise here. I am a doctor. Therefore, your statement is false. Burn.
I had exactly the same clinical experience as you did, Adam. I never wore a mask and neither did my patients. I never got covid either. Therefore, using your logic, I have proven that not masking is a wonderful thing.
I love much of what you do, but you are just dead wrong vis-a-vis masking. It is not bioplausible (took Vinay on regarding that long ago) and it makes the entire profession look silly when people say such things.
Do you want to know the definition of insanity? I went to the University of Michigan football game with two of my medical school classmates. One is a family physician practicing at a local medical school. The other is a hospitalist at the University of Michigan. We had 101,000 screaming fans- they were wearing masks.
I honestly think there was a psychological barrier for them. if they were that concerned that they were going to get Covid and that's a legitimate thought at the time they should not have been at the game.
Wearing the mask and that environment was no different than having a rabbits foot in their pocket.
If it made them feel better, psychologically I have no problem with that. But physicians come on we have to make judgments and give patients honest opinions.
As a cardiologist, we often do procedures that the truth be told are no different in outcome than decent medical therapy.
Here is the reality. if you die getting bypass surgery in 2024 that's acceptable and is an act of God. if you get medical therapy and die in 2028 it's because you didn't do the bypass in 2024..
I have discussion with patients all the time. It was different at that ball game.
Sorry it wouldn't let me edit it. The doctors were wearing masks. None of the other fans were. I had a great time and I didn't get Covid.
whew. I was incredulous in thinking that 101K football fans would be wearing masks appropriately ... thanks for clarifying!!
EBM...do we really know what any drugs or vaccines are doing to our bodies over the long term? No, nada, zilch, nothing...it's all guesswork, assumptions and approximation. Where is the evidence that your body is not being harmed? EBM is nothing but a whisper in the wind. It does not exist. But it is a great marketing tool and that is all modern medicine is about.
I agree with the characterization that most clinical decisions made in a day are done so in the absence of good evidence.
Partly, it’s because not every permutation of every clinical scenario can be properly addressed by an adequately powered RCT.
More importantly, the other Sackett pillars beyond scientific evidence (ie pt preferences, and pt comorbidities) will not be adequately reflected by RCTs even if a study is on-point for the clinical question itself.
So the majority of the time, we have to extrapolate from whatever evidence we do have, onto whichever patient’s particulars we are managing. And we do the best we can with the imperfect evidence we have. C’est La vie.
That’s not a call for nihilism, as we still need to do what we can to help the patient whilst avoiding harm, to the best of our knowledge. But it is a call to refrain from “guideline recommendations” that far overstep what is known. So I think your anecdotes are perfectly fine for your own practice. It’s only when people take such examples and make them into policy, where ire is deserved.
Wow, wouldn’t the world have a lot less STDs if people just decided to always wear a condom no matter what! 🤔
In the case of the doctor who masked and never got covid: in this scenario we aren’t considering potential other harms for example, maybe his anxious patient’s anxiety was worsen due to masked doctor or communication was inhibited resulting in poorer outcomes. In addition, because of our fragmented system, there maybe be some bad outcomes that the doctor never finds about because he doesn’t see that patient again so isn’t aware of longer term results
The best protection from infection is a healthy immune system. That requires a balanced omega-6/3 intake which seems to be rare in the World these days.
Bhutan has an interesting COVID-19 situation; 62,697 cases and 21 deaths. (Case/fatality rate: 2,986/1) The official explanation for the low mortality is that they masked up, vaccinated, and social distanced. https://www.who.int/about/accountability/results/who-results-report-2020-mtr/country-story/2021/bhutan# Unofficially, the citizens of that country do not consume much chicken because they prefer beef imported from India. Typically, ungulates have a much better omega fatty acid profile compared to monogastrics. Here's the problem with chicken. “Poultry meats, in particular chicken, have high rates of consumption globally. Poultry is the most consumed type of meat in the United States (US), with chicken being the most common type of poultry consumed. The amounts of chicken and total poultry consumed in the US have more than tripled over the last six decades… Limited evidence from randomized controlled trials indicates the consumption of lean unprocessed chicken as a primary dietary protein source has either beneficial or neutral effects on body weight and body composition and risk factors for CVD and T2DM. Apparently, zero randomized controlled feeding trials have specifically assessed the effects of consuming processed chicken/poultry on these health outcomes.” https://pubmed.ncbi.nlm.nih.gov/37630747/
It is reported that "Americans buy more chicken than any other food at the center of the plate. Chicken consumption per capita has increased nearly every year since the mid 1960’s, while red meat consumption has steadily declined." https://www.nationalchickencouncil.org/meat-sales-surged-77-the-week-of-march-15-amid-growing-covid-19-cases/
"People are eating an increasing number of chickens around the world, a trend that has already led to poultry topping charts as the most-consumed meat. The United States is no exception, and is even leading the charge. Chicken overtook beef as the country’s favorite meat in the 1990s. Now, U.S.-style factory farms — and the many problems associated with them — are spreading to countries around the world." https://sentientmedia.org/meat-consumption-in-the-us/
United states corona virus cases: 111,820,082. Deaths: 1,219,487 (Case/fatality rate: 92/1) Mortality was 32 times greater in the United States than in Bhutan.
Did they use Remdesivir and ventilators in Bhutan?
Right?! Did they have a death protocol in Bhutan? I think we were the only ones.
Thank you again Dr Cifu for your posts. I love your rigor tempered with humanity and seasoned with experience. Recipe for a valuable clinician.
Clinical experience should generate hypotheses and lead to trials. Doesn’t happen enough for a number of reasons. Pharma chokehold on what gets looked at wouldn’t be much interested in a generic drug effectiveness such as gaba in a “ suspect” population of pot users.
Similar to the use of prophylactic doxycycline for tick bites.
When I as a 35 year career as an oncology pharmacist was consulted on novel or off the grid treatment I would ask myself and discuss with the oncologist the downside risk in light of the patients current circumstances. If the risk of harm was acceptable and potential benefit was reasonable I would approve. Something my by the book younger colleagues were not always eager to do.
I would like to see Dr Prasad et al look at the data and literature for doxy prophylaxis in tick bites. It’s a terrifying downside risk for an almost harmless one time dose but does it stand up to scrutiny?
Here in Gloucester MA it’s not an insignificant risk
I'd love to see that study too. I'm in the Niagara region and ticks and lyme disease are becoming an issue here too. Public health has put up billboards showing the different kinds of ticks.
What if....respiratory viruses aren't spread through inhalation but as fomites? That is a trial I would like to see!!
Why is it that nobody ever mentions the characteristic Covid diarrhea that all the patient s had? Honestly, "science" may have been barking up the wrong tree all this time.
I'm not in the mood to go link hunting- help yourself- but I remember plenty of fomite studies during covid, which is why the "leave your groceries in your garage for 2 days and only approach in a class 3 suit" advice went away quietly.
Good to see you still alive and kicking, GM.
That makes one of us. Nice to see you too, doc. Keep fighting the good fight.
There were plenty of “studies” that “proved” masks worked also so…
There were, of course, no such studies.
We're agreeing with each other.
“Even if the opportunity presents itself, we would not be able to because no doctor would accept being randomized to no masking.“
Is this a joke?