Kevin T. Powell, MD, PhD

India is in a crisis as the burden of COVID-19 has collapsed parts of the health care system. There are not enough beds, not enough oxygen, and not enough crematoria to handle the pandemic. India is also a major supplier of vaccines for itself and many other countries. That production capacity has also been affected by the local events, further worsening the response to the pandemic over the next few months.

This collapse is the specter that, in April 2020, placed a hospital ship next to Manhattan and rows of beds in its convention center. Fortunately, the lockdown in March 2020 sufficiently flattened the curve. The city avoided utilizing that disaster capacity, though many New Yorkers died out of sight in nursing homes. When the third and largest wave of cases in the United States peaked in January 2021, hospitals throughout California reached capacity but avoided bursting. In April 2021, localized outbreaks in Michigan, Arizona, and Ontario again tested the maximum capacity for providing modern medical treatments. Great Britain used a second lockdown in October 2020 and a third in January 2021 to control the pandemic, with Prime Minister Boris Johnson emphasizing that it was these social interventions, and not vaccines, which provided the mitigating effects. Other European Union nations adopted similar strategies. Prudent choices by government guided by science, combined with the cooperation of the public, have been and still are crucial to mollify the pandemic.

There is hope that soon vaccines will return daily life to a new normal. In the United States, the Centers for Disease Control and Prevention has loosened restrictions on social gathering. An increase in daily new cases of COVID-19 in April 2021 has turned into just a blip before continuing to recede. Perhaps that is the first sign of vaccination working at the level of public health. However, the May 2021 lockdown in highly vaccinated Seychelles is a warning that the danger remains. A single match can start a huge forest fire. The first 150 million cases of COVID-19 worldwide have, through natural rates of mutation, produced several variants that might partially evade current vaccines. The danger of newer variants persists with the next 150 million cases as the pandemic continues to rage in many nations which are just one airplane ride away. All human inhabitants of this blue-covered third rock from the sun are interconnected.

The benefits of scientific advancement have been extolled for centuries. This includes both individual discoveries as well as a mindset that favors rationalism over fatalism. On the whole, the benefits of scientific progress outweigh the negatives. Negative environmental impacts include pollution and climate change. Economic impacts include raising the mean economic standard of living but with greater inequity. Historically, governmental and social institutions have attempted to mitigate these negative consequences. Those efforts have attempted to provide guidance and a moral compass to direct the progress of scientific advancement, particularly in fields like gene therapy. Those efforts have called upon developed nations to share the bounties of progress with other nations.

Modern medicine has provided the fruit of these scientific advancements to a limited fraction of the world’s population during the 20th century. The improvements in life expectancy and infant mortality have come primarily from civil engineers getting running water into cities and sewage out. A smaller portion of the benefits are from public health measures that reduced tuberculosis, smallpox, polio, and measles. Agriculture became more reliable, productive, and nutritious. In the 21st century, medical care (control of hypertension, diabetes, and clotting) aimed at reducing heart disease and strokes have added another 2-3 years to the life expectancy in the United States, with much of that benefit erased by the epidemics of obesity and opioid abuse.

Modern medical technology has created treatments that cost $10,000 a month to add a few extra months of life to geriatric patients with terminal cancer. Meanwhile, in more mundane care, efforts like Choosing Wisely seek to save money wasted on low-value, useless, and even harmful tests and therapies. There is no single person or agency managing this chaotic process of inventing expensive new technologies while inadequately addressing the widespread shortages of mental health care, disparities in education, and other social determinants of health. The pandemic has highlighted these preexisting weaknesses in the social fabric.

The cries from India have been accompanied by voices of anger from India and other nations accusing the United States of hoarding vaccines and the raw materials needed to produce them. This has been called vaccine apartheid. The United States is not alone in its political decision to prioritize domestic interests over international ones; India’s recent government is similarly nationalistic. Scientists warn that no one is safe locally as long as the pandemic rages in other countries. The Biden administration, in a delayed response to the crisis in India, finally announced plans to share some unused vaccines (of a brand not yet Food and Drug Administration approved) as well as some vaccine raw materials whose export was forbidden by a regulation under the Defense Production Act. Reading below the headlines, the promised response won’t be implemented for weeks or months. We must do better.

The logistics of sharing the benefits of advanced science are complicated. The ethics are not. Who is my neighbor? If you didn’t learn the answer to that in Sunday school, there isn’t much more I can say.

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no financial disclosures, Email him at pdnews@mdedge.com

India is in a crisis as the burden of COVID-19 has collapsed parts of the health care system. There are not enough beds, not enough oxygen, and not enough crematoria to handle the pandemic. India is also a major supplier of vaccines for itself and many other countries. That production capacity has also been affected by the local events, further worsening the response to the pandemic over the next few months.

This collapse is the specter that, in April 2020, placed a hospital ship next to Manhattan and rows of beds in its convention center. Fortunately, the lockdown in March 2020 sufficiently flattened the curve. The city avoided utilizing that disaster capacity, though many New Yorkers died out of sight in nursing homes. When the third and largest wave of cases in the United States peaked in January 2021, hospitals throughout California reached capacity but avoided bursting. In April 2021, localized outbreaks in Michigan, Arizona, and Ontario again tested the maximum capacity for providing modern medical treatments. Great Britain used a second lockdown in October 2020 and a third in January 2021 to control the pandemic, with Prime Minister Boris Johnson emphasizing that it was these social interventions, and not vaccines, which provided the mitigating effects. Other European Union nations adopted similar strategies. Prudent choices by government guided by science, combined with the cooperation of the public, have been and still are crucial to mollify the pandemic.

There is hope that soon vaccines will return daily life to a new normal. In the United States, the Centers for Disease Control and Prevention has loosened restrictions on social gathering. An increase in daily new cases of COVID-19 in April 2021 has turned into just a blip before continuing to recede. Perhaps that is the first sign of vaccination working at the level of public health. However, the May 2021 lockdown in highly vaccinated Seychelles is a warning that the danger remains. A single match can start a huge forest fire. The first 150 million cases of COVID-19 worldwide have, through natural rates of mutation, produced several variants that might partially evade current vaccines. The danger of newer variants persists with the next 150 million cases as the pandemic continues to rage in many nations which are just one airplane ride away. All human inhabitants of this blue-covered third rock from the sun are interconnected.

The benefits of scientific advancement have been extolled for centuries. This includes both individual discoveries as well as a mindset that favors rationalism over fatalism. On the whole, the benefits of scientific progress outweigh the negatives. Negative environmental impacts include pollution and climate change. Economic impacts include raising the mean economic standard of living but with greater inequity. Historically, governmental and social institutions have attempted to mitigate these negative consequences. Those efforts have attempted to provide guidance and a moral compass to direct the progress of scientific advancement, particularly in fields like gene therapy. Those efforts have called upon developed nations to share the bounties of progress with other nations.

Modern medicine has provided the fruit of these scientific advancements to a limited fraction of the world’s population during the 20th century. The improvements in life expectancy and infant mortality have come primarily from civil engineers getting running water into cities and sewage out. A smaller portion of the benefits are from public health measures that reduced tuberculosis, smallpox, polio, and measles. Agriculture became more reliable, productive, and nutritious. In the 21st century, medical care (control of hypertension, diabetes, and clotting) aimed at reducing heart disease and strokes have added another 2-3 years to the life expectancy in the United States, with much of that benefit erased by the epidemics of obesity and opioid abuse.

Modern medical technology has created treatments that cost $10,000 a month to add a few extra months of life to geriatric patients with terminal cancer. Meanwhile, in more mundane care, efforts like Choosing Wisely seek to save money wasted on low-value, useless, and even harmful tests and therapies. There is no single person or agency managing this chaotic process of inventing expensive new technologies while inadequately addressing the widespread shortages of mental health care, disparities in education, and other social determinants of health. The pandemic has highlighted these preexisting weaknesses in the social fabric.

The cries from India have been accompanied by voices of anger from India and other nations accusing the United States of hoarding vaccines and the raw materials needed to produce them. This has been called vaccine apartheid. The United States is not alone in its political decision to prioritize domestic interests over international ones; India’s recent government is similarly nationalistic. Scientists warn that no one is safe locally as long as the pandemic rages in other countries. The Biden administration, in a delayed response to the crisis in India, finally announced plans to share some unused vaccines (of a brand not yet Food and Drug Administration approved) as well as some vaccine raw materials whose export was forbidden by a regulation under the Defense Production Act. Reading below the headlines, the promised response won’t be implemented for weeks or months. We must do better.

The logistics of sharing the benefits of advanced science are complicated. The ethics are not. Who is my neighbor? If you didn’t learn the answer to that in Sunday school, there isn’t much more I can say.

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no financial disclosures, Email him at pdnews@mdedge.com

India is in a crisis as the burden of COVID-19 has collapsed parts of the health care system. There are not enough beds, not enough oxygen, and not enough crematoria to handle the pandemic. India is also a major supplier of vaccines for itself and many other countries. That production capacity has also been affected by the local events, further worsening the response to the pandemic over the next few months.

This collapse is the specter that, in April 2020, placed a hospital ship next to Manhattan and rows of beds in its convention center. Fortunately, the lockdown in March 2020 sufficiently flattened the curve. The city avoided utilizing that disaster capacity, though many New Yorkers died out of sight in nursing homes. When the third and largest wave of cases in the United States peaked in January 2021, hospitals throughout California reached capacity but avoided bursting. In April 2021, localized outbreaks in Michigan, Arizona, and Ontario again tested the maximum capacity for providing modern medical treatments. Great Britain used a second lockdown in October 2020 and a third in January 2021 to control the pandemic, with Prime Minister Boris Johnson emphasizing that it was these social interventions, and not vaccines, which provided the mitigating effects. Other European Union nations adopted similar strategies. Prudent choices by government guided by science, combined with the cooperation of the public, have been and still are crucial to mollify the pandemic.

There is hope that soon vaccines will return daily life to a new normal. In the United States, the Centers for Disease Control and Prevention has loosened restrictions on social gathering. An increase in daily new cases of COVID-19 in April 2021 has turned into just a blip before continuing to recede. Perhaps that is the first sign of vaccination working at the level of public health. However, the May 2021 lockdown in highly vaccinated Seychelles is a warning that the danger remains. A single match can start a huge forest fire. The first 150 million cases of COVID-19 worldwide have, through natural rates of mutation, produced several variants that might partially evade current vaccines. The danger of newer variants persists with the next 150 million cases as the pandemic continues to rage in many nations which are just one airplane ride away. All human inhabitants of this blue-covered third rock from the sun are interconnected.

The benefits of scientific advancement have been extolled for centuries. This includes both individual discoveries as well as a mindset that favors rationalism over fatalism. On the whole, the benefits of scientific progress outweigh the negatives. Negative environmental impacts include pollution and climate change. Economic impacts include raising the mean economic standard of living but with greater inequity. Historically, governmental and social institutions have attempted to mitigate these negative consequences. Those efforts have attempted to provide guidance and a moral compass to direct the progress of scientific advancement, particularly in fields like gene therapy. Those efforts have called upon developed nations to share the bounties of progress with other nations.

Modern medicine has provided the fruit of these scientific advancements to a limited fraction of the world’s population during the 20th century. The improvements in life expectancy and infant mortality have come primarily from civil engineers getting running water into cities and sewage out. A smaller portion of the benefits are from public health measures that reduced tuberculosis, smallpox, polio, and measles. Agriculture became more reliable, productive, and nutritious. In the 21st century, medical care (control of hypertension, diabetes, and clotting) aimed at reducing heart disease and strokes have added another 2-3 years to the life expectancy in the United States, with much of that benefit erased by the epidemics of obesity and opioid abuse.

Modern medical technology has created treatments that cost $10,000 a month to add a few extra months of life to geriatric patients with terminal cancer. Meanwhile, in more mundane care, efforts like Choosing Wisely seek to save money wasted on low-value, useless, and even harmful tests and therapies. There is no single person or agency managing this chaotic process of inventing expensive new technologies while inadequately addressing the widespread shortages of mental health care, disparities in education, and other social determinants of health. The pandemic has highlighted these preexisting weaknesses in the social fabric.

The cries from India have been accompanied by voices of anger from India and other nations accusing the United States of hoarding vaccines and the raw materials needed to produce them. This has been called vaccine apartheid. The United States is not alone in its political decision to prioritize domestic interests over international ones; India’s recent government is similarly nationalistic. Scientists warn that no one is safe locally as long as the pandemic rages in other countries. The Biden administration, in a delayed response to the crisis in India, finally announced plans to share some unused vaccines (of a brand not yet Food and Drug Administration approved) as well as some vaccine raw materials whose export was forbidden by a regulation under the Defense Production Act. Reading below the headlines, the promised response won’t be implemented for weeks or months. We must do better.

The logistics of sharing the benefits of advanced science are complicated. The ethics are not. Who is my neighbor? If you didn’t learn the answer to that in Sunday school, there isn’t much more I can say.

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no financial disclosures, Email him at pdnews@mdedge.com

For the near future, it is hard to imagine anything having a larger impact on children’s health than the need to reopen schools.

There are many social determinants of health and many of those have been, appropriately, more strongly tied to schools than to health care. Academics are important, and those are best delivered by trained educators. Nutrition is important; hot lunch programs play an important role in ensuring children don’t go hungry. Schools are a major source of day care that allows parent(s) to work and to have a career through which family income potentials increase. Schools are a location for children to socialize, to form friendships, to participate in teams, and to promote wellness. This is only a partial list, but I’m preaching to the choir with this column.

Science, though imperfect, has advanced in the 1 year since the shutdown. I am thrilled to see policy makers embracing a scientific basis for policy making. (I’ll be more thrilled if it actually happens.) There is now accumulated evidence of harm associated with children not being in schools. There is accumulated evidence that the absolute magnitude of illness transmitted in elementary schools is small, though I can’t find any researcher defining what is small enough. There is accumulated evidence that the risk of transmission of COVID-19 in schools can be mitigated with a variety of interventions that include wearing masks, spacing desks, cohorting in small classes, good ventilation, and vaccines for the teachers. It is, however, unclear how much benefit comes from each intervention. That uncertainty makes it difficult for parents and teachers to assess whether, given limited financial resources, individual school districts have prepared adequately. Teachers, like pediatricians, are dedicated to doing what is best for children. Both teachers and pediatricians are aware that sometimes administrators and politicians take unfair advantage of this commitment to children.

There is an expectation that, with 130,000 schools in the United States, some fraction of them will have outbreaks that will generate illnesses, deaths, and bad publicity. The number and degree of these outbreaks will be best mitigated by lowering the number of new cases per day in the community. Estimates are that 89%-99% of children live in so-called red zones under the Centers for Disease Control and Prevention’s guidance – meaning there is a high level of community spread of the virus. In mid-February, the CDC released new guidelines for mitigating transmission within the schools. Those guidelines seemed to make it unlikely that schools in red zones could safely reopen, but over the following week, CDC Director Rochelle Walensky walked back that notion.

So, is it “safe” to reopen the schools? As a pediatrician, I have read more on this subject than the vast majority of people in my city. I have discussed the subject with colleagues who are far more informed than I. Still, I am in not in a position to synthesize all that research. I cannot advise neighbors, parents, or church groups about this subject. This column is not going to propose a solution. I will suggest a process based on professionalism and medical ethics.

The actors in this process need to be trustworthy. Medical residents are taught that patients/parents first need to see that you are committed (to benefiting them) before they can see that you are competent. Trust in the relationship with patients is maintained with truthfulness, by embracing the professional responsibilities of a fiduciary, and by expressing commitment and compassion.

Facts should be determined based on sound science. Values should be determined with input from all stakeholders. Decision-making based on facts and values should occur transparently within trusted institutions.

Which institutions should we trust?

My recommendation, biased by my experience, is to trust the CDC. It is composed of full-time, well-funded researchers (in basic science, in medicine, and in public health policy) who have dedicated years toward lofty goals. The CDC policy-making system has recently been pressured by inappropriate political maneuvering that has shaded its integrity.

The American Academy of Pediatrics has also been providing guidance favoring reopening schools. Its committees are mostly composed of volunteers dedicated to improving the health of children. I’ve become slightly jaded by participation in the sausage-making behind its policy statements. I doubt that teachers are reassured by focusing attention on the AAP’s claims to advocate for children.

State education boards contain experts dedicated to the well-being of children. Local boards of education have less expertise and less ability to resist political persuasion, but offer disseminated decision-making.

Will parents and children heed the advice? So far, there are stories that schools which have reopened with optional and hybrid models have not seen the return of the masses. There are also many stories of schools that have stayed open throughout the pandemic without catastrophic consequences. In the near future, I would not expect more science to be persuasive. Finding a way forward will be more dependent on rebuilding trust in institutions.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

For the near future, it is hard to imagine anything having a larger impact on children’s health than the need to reopen schools.

There are many social determinants of health and many of those have been, appropriately, more strongly tied to schools than to health care. Academics are important, and those are best delivered by trained educators. Nutrition is important; hot lunch programs play an important role in ensuring children don’t go hungry. Schools are a major source of day care that allows parent(s) to work and to have a career through which family income potentials increase. Schools are a location for children to socialize, to form friendships, to participate in teams, and to promote wellness. This is only a partial list, but I’m preaching to the choir with this column.

Science, though imperfect, has advanced in the 1 year since the shutdown. I am thrilled to see policy makers embracing a scientific basis for policy making. (I’ll be more thrilled if it actually happens.) There is now accumulated evidence of harm associated with children not being in schools. There is accumulated evidence that the absolute magnitude of illness transmitted in elementary schools is small, though I can’t find any researcher defining what is small enough. There is accumulated evidence that the risk of transmission of COVID-19 in schools can be mitigated with a variety of interventions that include wearing masks, spacing desks, cohorting in small classes, good ventilation, and vaccines for the teachers. It is, however, unclear how much benefit comes from each intervention. That uncertainty makes it difficult for parents and teachers to assess whether, given limited financial resources, individual school districts have prepared adequately. Teachers, like pediatricians, are dedicated to doing what is best for children. Both teachers and pediatricians are aware that sometimes administrators and politicians take unfair advantage of this commitment to children.

There is an expectation that, with 130,000 schools in the United States, some fraction of them will have outbreaks that will generate illnesses, deaths, and bad publicity. The number and degree of these outbreaks will be best mitigated by lowering the number of new cases per day in the community. Estimates are that 89%-99% of children live in so-called red zones under the Centers for Disease Control and Prevention’s guidance – meaning there is a high level of community spread of the virus. In mid-February, the CDC released new guidelines for mitigating transmission within the schools. Those guidelines seemed to make it unlikely that schools in red zones could safely reopen, but over the following week, CDC Director Rochelle Walensky walked back that notion.

So, is it “safe” to reopen the schools? As a pediatrician, I have read more on this subject than the vast majority of people in my city. I have discussed the subject with colleagues who are far more informed than I. Still, I am in not in a position to synthesize all that research. I cannot advise neighbors, parents, or church groups about this subject. This column is not going to propose a solution. I will suggest a process based on professionalism and medical ethics.

The actors in this process need to be trustworthy. Medical residents are taught that patients/parents first need to see that you are committed (to benefiting them) before they can see that you are competent. Trust in the relationship with patients is maintained with truthfulness, by embracing the professional responsibilities of a fiduciary, and by expressing commitment and compassion.

Facts should be determined based on sound science. Values should be determined with input from all stakeholders. Decision-making based on facts and values should occur transparently within trusted institutions.

Which institutions should we trust?

My recommendation, biased by my experience, is to trust the CDC. It is composed of full-time, well-funded researchers (in basic science, in medicine, and in public health policy) who have dedicated years toward lofty goals. The CDC policy-making system has recently been pressured by inappropriate political maneuvering that has shaded its integrity.

The American Academy of Pediatrics has also been providing guidance favoring reopening schools. Its committees are mostly composed of volunteers dedicated to improving the health of children. I’ve become slightly jaded by participation in the sausage-making behind its policy statements. I doubt that teachers are reassured by focusing attention on the AAP’s claims to advocate for children.

State education boards contain experts dedicated to the well-being of children. Local boards of education have less expertise and less ability to resist political persuasion, but offer disseminated decision-making.

Will parents and children heed the advice? So far, there are stories that schools which have reopened with optional and hybrid models have not seen the return of the masses. There are also many stories of schools that have stayed open throughout the pandemic without catastrophic consequences. In the near future, I would not expect more science to be persuasive. Finding a way forward will be more dependent on rebuilding trust in institutions.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

For the near future, it is hard to imagine anything having a larger impact on children’s health than the need to reopen schools.

There are many social determinants of health and many of those have been, appropriately, more strongly tied to schools than to health care. Academics are important, and those are best delivered by trained educators. Nutrition is important; hot lunch programs play an important role in ensuring children don’t go hungry. Schools are a major source of day care that allows parent(s) to work and to have a career through which family income potentials increase. Schools are a location for children to socialize, to form friendships, to participate in teams, and to promote wellness. This is only a partial list, but I’m preaching to the choir with this column.

Science, though imperfect, has advanced in the 1 year since the shutdown. I am thrilled to see policy makers embracing a scientific basis for policy making. (I’ll be more thrilled if it actually happens.) There is now accumulated evidence of harm associated with children not being in schools. There is accumulated evidence that the absolute magnitude of illness transmitted in elementary schools is small, though I can’t find any researcher defining what is small enough. There is accumulated evidence that the risk of transmission of COVID-19 in schools can be mitigated with a variety of interventions that include wearing masks, spacing desks, cohorting in small classes, good ventilation, and vaccines for the teachers. It is, however, unclear how much benefit comes from each intervention. That uncertainty makes it difficult for parents and teachers to assess whether, given limited financial resources, individual school districts have prepared adequately. Teachers, like pediatricians, are dedicated to doing what is best for children. Both teachers and pediatricians are aware that sometimes administrators and politicians take unfair advantage of this commitment to children.

There is an expectation that, with 130,000 schools in the United States, some fraction of them will have outbreaks that will generate illnesses, deaths, and bad publicity. The number and degree of these outbreaks will be best mitigated by lowering the number of new cases per day in the community. Estimates are that 89%-99% of children live in so-called red zones under the Centers for Disease Control and Prevention’s guidance – meaning there is a high level of community spread of the virus. In mid-February, the CDC released new guidelines for mitigating transmission within the schools. Those guidelines seemed to make it unlikely that schools in red zones could safely reopen, but over the following week, CDC Director Rochelle Walensky walked back that notion.

So, is it “safe” to reopen the schools? As a pediatrician, I have read more on this subject than the vast majority of people in my city. I have discussed the subject with colleagues who are far more informed than I. Still, I am in not in a position to synthesize all that research. I cannot advise neighbors, parents, or church groups about this subject. This column is not going to propose a solution. I will suggest a process based on professionalism and medical ethics.

The actors in this process need to be trustworthy. Medical residents are taught that patients/parents first need to see that you are committed (to benefiting them) before they can see that you are competent. Trust in the relationship with patients is maintained with truthfulness, by embracing the professional responsibilities of a fiduciary, and by expressing commitment and compassion.

Facts should be determined based on sound science. Values should be determined with input from all stakeholders. Decision-making based on facts and values should occur transparently within trusted institutions.

Which institutions should we trust?

My recommendation, biased by my experience, is to trust the CDC. It is composed of full-time, well-funded researchers (in basic science, in medicine, and in public health policy) who have dedicated years toward lofty goals. The CDC policy-making system has recently been pressured by inappropriate political maneuvering that has shaded its integrity.

The American Academy of Pediatrics has also been providing guidance favoring reopening schools. Its committees are mostly composed of volunteers dedicated to improving the health of children. I’ve become slightly jaded by participation in the sausage-making behind its policy statements. I doubt that teachers are reassured by focusing attention on the AAP’s claims to advocate for children.

State education boards contain experts dedicated to the well-being of children. Local boards of education have less expertise and less ability to resist political persuasion, but offer disseminated decision-making.

Will parents and children heed the advice? So far, there are stories that schools which have reopened with optional and hybrid models have not seen the return of the masses. There are also many stories of schools that have stayed open throughout the pandemic without catastrophic consequences. In the near future, I would not expect more science to be persuasive. Finding a way forward will be more dependent on rebuilding trust in institutions.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

Many scientific problems are complex. Finding the solution can require the concerted efforts of a team. Producing a vaccine for COVID-19 involved a multidisciplinary team with a variety of highly specialized expertises, extensive technological resources, and a history of previous scientific discoveries upon whose shoulders today’s scientists can stand.

Many ethical problems are also complex. Finding the ideal, multifaceted answer that addresses all the nuances of a social problem requires brilliant minds, a refined ability for logical analysis and rhetoric, the empowerment of the voices of all stakeholders, and attention to social values such as diversity and justice.

In both endeavors, the typical scientists and ethicists involved tend to presume that if they can determine an ideal solution, it will be rapidly and enthusiastically adopted and implemented for the betterment of society. That is, after all, exactly how those researchers would choose to act. Scientists see moral actions as having two steps. The hard part is deciding what is right. Doing the right thing is the easier task. This delusion is ubiquitous. Many scientists and ethicists recognize the delusion of the existence of a rational society, but proceed anyhow as if one exists.

There is a chorus of voices capable of debunking this delusion. Any priest who hears confessions will testify that the vast majority of harm comes from the failure to do what people already know is right, not from uncertainty, confusion, or ignorance. Psychologists and substance abuse counselors are inundated with people who are stuck doing harmful and self-destructive acts. Internists discuss diet and exercise with their patients, but find the advice is infrequently adopted. Master in business administration programs are devoted to training graduates in methods of motivating people to do what is right.

The response of the scientific establishment to the COVID-19 pandemic was imperfect. There were gaps in knowledge and some early information from China was misleading. The initial CDC test kit production was flawed. The early appeal for the public not to buy masks was strongly driven by a desire to preserve supplies for health care workers. Despite these missteps, the overall advice of scientists was wildly successful and beneficial. The goal was to flatten the curve, and a comparison of the April-June time frame with the November-January period shows markedly fewer COVID-19 cases, hospitalizations, and deaths. Confronted with the pandemic of the century, my assessment is that scientific establishment has performed well.

I am far more negative in my assessment of the institutions that support morality, form the social order, establish justice, and promote the general welfare. For instance, misinformation on social media is rampant, including conspiracy theories and outright denials of the pandemic. Scientific advice has been undercut and impugned. Policy recommendations of esteemed scientific institutions have been ignored. The public’s cooperation has fatigued. Laws on public gatherings, quarantines, and social distancing have been broken. Communitarian ethics and devotion to the common good have been left in a trash heap. The consequences have been hundreds of thousands of lives lost in 2020 and some states are on the brink of much worse.

Medical ethicists have debated in fine detail how to triage ventilators, ration antibody treatments, and prioritize vaccinations. Those policy recommendations have had limited influence. Medical ethics has inadequately addressed the age old problem of morality, which is getting people to behave as they know they ought. Modern medical ethics may have exacerbated the deviancy. Medical ethics for 50 years has emphasized replacing paternalism with autonomy, but it has not adequately promoted communitarian virtues, self-regulation, and personal integrity.

There were many accomplishments and many people to admire in 2020 when compared to historical actions by the health care professionals during crises. Doctors, confronted with the COVID-19 plague, have not abandoned the cities as happened in prior centuries. Patients have not been shunned like lepers, though the total-body protective equipment and the no-visitor policies come very close. Nurses have heroically provided bedside care, though I am haunted by one dissident nurse during a protest carrying a sign saying “Don’t call me a hero. I am being martyred against my will.”

As a scientist, I am prone to the delusion that, if I can build a better mouse trap, people will use it. I’ve lived with that delusion for decades. It carries over into my medical ethics work. Yet I see hospitals in California being overwhelmed by the surge on top of a surge due to unwise and unsafe holiday travel. I can see that optimized solutions aren’t the answer – it is better behavior by the public. I recall when I was a child, my mother would simply command, “Behave yourself.” And never, in any of those recollections, was I in doubt about which correct behavior she meant.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

Many scientific problems are complex. Finding the solution can require the concerted efforts of a team. Producing a vaccine for COVID-19 involved a multidisciplinary team with a variety of highly specialized expertises, extensive technological resources, and a history of previous scientific discoveries upon whose shoulders today’s scientists can stand.

Many ethical problems are also complex. Finding the ideal, multifaceted answer that addresses all the nuances of a social problem requires brilliant minds, a refined ability for logical analysis and rhetoric, the empowerment of the voices of all stakeholders, and attention to social values such as diversity and justice.

In both endeavors, the typical scientists and ethicists involved tend to presume that if they can determine an ideal solution, it will be rapidly and enthusiastically adopted and implemented for the betterment of society. That is, after all, exactly how those researchers would choose to act. Scientists see moral actions as having two steps. The hard part is deciding what is right. Doing the right thing is the easier task. This delusion is ubiquitous. Many scientists and ethicists recognize the delusion of the existence of a rational society, but proceed anyhow as if one exists.

There is a chorus of voices capable of debunking this delusion. Any priest who hears confessions will testify that the vast majority of harm comes from the failure to do what people already know is right, not from uncertainty, confusion, or ignorance. Psychologists and substance abuse counselors are inundated with people who are stuck doing harmful and self-destructive acts. Internists discuss diet and exercise with their patients, but find the advice is infrequently adopted. Master in business administration programs are devoted to training graduates in methods of motivating people to do what is right.

The response of the scientific establishment to the COVID-19 pandemic was imperfect. There were gaps in knowledge and some early information from China was misleading. The initial CDC test kit production was flawed. The early appeal for the public not to buy masks was strongly driven by a desire to preserve supplies for health care workers. Despite these missteps, the overall advice of scientists was wildly successful and beneficial. The goal was to flatten the curve, and a comparison of the April-June time frame with the November-January period shows markedly fewer COVID-19 cases, hospitalizations, and deaths. Confronted with the pandemic of the century, my assessment is that scientific establishment has performed well.

I am far more negative in my assessment of the institutions that support morality, form the social order, establish justice, and promote the general welfare. For instance, misinformation on social media is rampant, including conspiracy theories and outright denials of the pandemic. Scientific advice has been undercut and impugned. Policy recommendations of esteemed scientific institutions have been ignored. The public’s cooperation has fatigued. Laws on public gatherings, quarantines, and social distancing have been broken. Communitarian ethics and devotion to the common good have been left in a trash heap. The consequences have been hundreds of thousands of lives lost in 2020 and some states are on the brink of much worse.

Medical ethicists have debated in fine detail how to triage ventilators, ration antibody treatments, and prioritize vaccinations. Those policy recommendations have had limited influence. Medical ethics has inadequately addressed the age old problem of morality, which is getting people to behave as they know they ought. Modern medical ethics may have exacerbated the deviancy. Medical ethics for 50 years has emphasized replacing paternalism with autonomy, but it has not adequately promoted communitarian virtues, self-regulation, and personal integrity.

There were many accomplishments and many people to admire in 2020 when compared to historical actions by the health care professionals during crises. Doctors, confronted with the COVID-19 plague, have not abandoned the cities as happened in prior centuries. Patients have not been shunned like lepers, though the total-body protective equipment and the no-visitor policies come very close. Nurses have heroically provided bedside care, though I am haunted by one dissident nurse during a protest carrying a sign saying “Don’t call me a hero. I am being martyred against my will.”

As a scientist, I am prone to the delusion that, if I can build a better mouse trap, people will use it. I’ve lived with that delusion for decades. It carries over into my medical ethics work. Yet I see hospitals in California being overwhelmed by the surge on top of a surge due to unwise and unsafe holiday travel. I can see that optimized solutions aren’t the answer – it is better behavior by the public. I recall when I was a child, my mother would simply command, “Behave yourself.” And never, in any of those recollections, was I in doubt about which correct behavior she meant.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

Many scientific problems are complex. Finding the solution can require the concerted efforts of a team. Producing a vaccine for COVID-19 involved a multidisciplinary team with a variety of highly specialized expertises, extensive technological resources, and a history of previous scientific discoveries upon whose shoulders today’s scientists can stand.

Many ethical problems are also complex. Finding the ideal, multifaceted answer that addresses all the nuances of a social problem requires brilliant minds, a refined ability for logical analysis and rhetoric, the empowerment of the voices of all stakeholders, and attention to social values such as diversity and justice.

In both endeavors, the typical scientists and ethicists involved tend to presume that if they can determine an ideal solution, it will be rapidly and enthusiastically adopted and implemented for the betterment of society. That is, after all, exactly how those researchers would choose to act. Scientists see moral actions as having two steps. The hard part is deciding what is right. Doing the right thing is the easier task. This delusion is ubiquitous. Many scientists and ethicists recognize the delusion of the existence of a rational society, but proceed anyhow as if one exists.

There is a chorus of voices capable of debunking this delusion. Any priest who hears confessions will testify that the vast majority of harm comes from the failure to do what people already know is right, not from uncertainty, confusion, or ignorance. Psychologists and substance abuse counselors are inundated with people who are stuck doing harmful and self-destructive acts. Internists discuss diet and exercise with their patients, but find the advice is infrequently adopted. Master in business administration programs are devoted to training graduates in methods of motivating people to do what is right.

The response of the scientific establishment to the COVID-19 pandemic was imperfect. There were gaps in knowledge and some early information from China was misleading. The initial CDC test kit production was flawed. The early appeal for the public not to buy masks was strongly driven by a desire to preserve supplies for health care workers. Despite these missteps, the overall advice of scientists was wildly successful and beneficial. The goal was to flatten the curve, and a comparison of the April-June time frame with the November-January period shows markedly fewer COVID-19 cases, hospitalizations, and deaths. Confronted with the pandemic of the century, my assessment is that scientific establishment has performed well.

I am far more negative in my assessment of the institutions that support morality, form the social order, establish justice, and promote the general welfare. For instance, misinformation on social media is rampant, including conspiracy theories and outright denials of the pandemic. Scientific advice has been undercut and impugned. Policy recommendations of esteemed scientific institutions have been ignored. The public’s cooperation has fatigued. Laws on public gatherings, quarantines, and social distancing have been broken. Communitarian ethics and devotion to the common good have been left in a trash heap. The consequences have been hundreds of thousands of lives lost in 2020 and some states are on the brink of much worse.

Medical ethicists have debated in fine detail how to triage ventilators, ration antibody treatments, and prioritize vaccinations. Those policy recommendations have had limited influence. Medical ethics has inadequately addressed the age old problem of morality, which is getting people to behave as they know they ought. Modern medical ethics may have exacerbated the deviancy. Medical ethics for 50 years has emphasized replacing paternalism with autonomy, but it has not adequately promoted communitarian virtues, self-regulation, and personal integrity.

There were many accomplishments and many people to admire in 2020 when compared to historical actions by the health care professionals during crises. Doctors, confronted with the COVID-19 plague, have not abandoned the cities as happened in prior centuries. Patients have not been shunned like lepers, though the total-body protective equipment and the no-visitor policies come very close. Nurses have heroically provided bedside care, though I am haunted by one dissident nurse during a protest carrying a sign saying “Don’t call me a hero. I am being martyred against my will.”

As a scientist, I am prone to the delusion that, if I can build a better mouse trap, people will use it. I’ve lived with that delusion for decades. It carries over into my medical ethics work. Yet I see hospitals in California being overwhelmed by the surge on top of a surge due to unwise and unsafe holiday travel. I can see that optimized solutions aren’t the answer – it is better behavior by the public. I recall when I was a child, my mother would simply command, “Behave yourself.” And never, in any of those recollections, was I in doubt about which correct behavior she meant.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

Early autumn is typically a quiet time for outpatient pediatricians. The school physicals are finished. The last-minute school physicals are finished. The “I forgot to get my child’s physical” physicals are finished. Respiratory syncytial virus and influenza seasons haven’t started. There is time for some self-reflection and sharpening the saw.

My reflective period each year tends to start with the unresolved “What do I want to be when I grow up?” Mind you, just because I’ve grown old doesn’t mean I’ve grown up. I never wanted to be a “grande personne” who, per Antoine de Saint-Exupéry in “Le Petit Prince,” will never understand why a minor item (Did the lamb eat the flower?) makes all the difference in the universe to a child. Awe and wonderment should remain a part of life. I enjoy reading that short story in the original French because, as my high school French vocabulary and conjugation have faded, any word I don’t recognize means exactly what my journey of a lifetime tells me it means, neither more nor less, just as Humpty Dumpty explained to Alice in Lewis Carroll’s “Through the Looking Glass.”

Along with my perennial favorites like “Le Petit Prince” and the Gettysburg Address, in this year’s folder for reflection are two essays I’ve collected this year. The first is a letter addressed from medical ethicist Ira Bedzow, PhD, to this year’s incoming class of medical students.

The essay gives advice to first-year medical students entering the profession of medicine. It talks about finding “something to say that you communicate with the whole and essence of your being.” There is lots of great counsel in the letter. It claims, “Only in a professional does one’s voice sing in harmony with one’s being. Want that for yourselves, for only a life undivided is a life of full integrity.”

I agree with the harmony part. I hesitate with the undivided part. A professional singer could be dedicated to opera but still sing in a barbershop quartet and a church choir, motivated by fun and fellowship. It is important to emphasize integrity and dedication to medical students. The letter does that well, but students must also develop a work-life balance. The ascetic life is not for everyone.

Life needs balance and moderation. I am pretty sure that Aristotle said that, but I never did spend much time studying the Classics. I use my periods of self-reflection to chart my life’s vector. I choose new skills to learn and challenges to meet. But as I grow older, I spend more time pruning those roles that no longer give me joy. Delayed gratification is an important character trait for success, but its value lessens as it becomes clear there are more days behind me than ahead.

The second essay reflects the views of Canon Brodar, a third-year medical student and divinity school graduate.

He attests to the willingness of medical trainees to accept their duties and personal risk during the crisis of the COVID-19 pandemic. He correctly points out the contributions his fellow students could make, but underestimates the negatives. During March 2020 when decisions were made to send third-year medical students home, the administrative focus was on the cost of their participation (consumption of scarce personal protective equipment) and the potential negative consequences (an additional person who might transmit the virus among patients.) Four months later, most medical students were back on the job.

Mr. Brodar’s eloquent description of duty and responsibility complement, and perhaps have evolved from, the integrity and dedication that Dr. Bedzow emphasized to incoming medical students. These are all character traits. These traits are not knowledge of anatomy or skill with a scalpel. They are attitudes that colleagues hope and expect to find in any person who puts on the white coat. With experience come two more key character traits – the moderation of a work-life balance and the judgment to weigh benefits, risks, and costs.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

Early autumn is typically a quiet time for outpatient pediatricians. The school physicals are finished. The last-minute school physicals are finished. The “I forgot to get my child’s physical” physicals are finished. Respiratory syncytial virus and influenza seasons haven’t started. There is time for some self-reflection and sharpening the saw.

My reflective period each year tends to start with the unresolved “What do I want to be when I grow up?” Mind you, just because I’ve grown old doesn’t mean I’ve grown up. I never wanted to be a “grande personne” who, per Antoine de Saint-Exupéry in “Le Petit Prince,” will never understand why a minor item (Did the lamb eat the flower?) makes all the difference in the universe to a child. Awe and wonderment should remain a part of life. I enjoy reading that short story in the original French because, as my high school French vocabulary and conjugation have faded, any word I don’t recognize means exactly what my journey of a lifetime tells me it means, neither more nor less, just as Humpty Dumpty explained to Alice in Lewis Carroll’s “Through the Looking Glass.”

Along with my perennial favorites like “Le Petit Prince” and the Gettysburg Address, in this year’s folder for reflection are two essays I’ve collected this year. The first is a letter addressed from medical ethicist Ira Bedzow, PhD, to this year’s incoming class of medical students.

The essay gives advice to first-year medical students entering the profession of medicine. It talks about finding “something to say that you communicate with the whole and essence of your being.” There is lots of great counsel in the letter. It claims, “Only in a professional does one’s voice sing in harmony with one’s being. Want that for yourselves, for only a life undivided is a life of full integrity.”

I agree with the harmony part. I hesitate with the undivided part. A professional singer could be dedicated to opera but still sing in a barbershop quartet and a church choir, motivated by fun and fellowship. It is important to emphasize integrity and dedication to medical students. The letter does that well, but students must also develop a work-life balance. The ascetic life is not for everyone.

Life needs balance and moderation. I am pretty sure that Aristotle said that, but I never did spend much time studying the Classics. I use my periods of self-reflection to chart my life’s vector. I choose new skills to learn and challenges to meet. But as I grow older, I spend more time pruning those roles that no longer give me joy. Delayed gratification is an important character trait for success, but its value lessens as it becomes clear there are more days behind me than ahead.

The second essay reflects the views of Canon Brodar, a third-year medical student and divinity school graduate.

He attests to the willingness of medical trainees to accept their duties and personal risk during the crisis of the COVID-19 pandemic. He correctly points out the contributions his fellow students could make, but underestimates the negatives. During March 2020 when decisions were made to send third-year medical students home, the administrative focus was on the cost of their participation (consumption of scarce personal protective equipment) and the potential negative consequences (an additional person who might transmit the virus among patients.) Four months later, most medical students were back on the job.

Mr. Brodar’s eloquent description of duty and responsibility complement, and perhaps have evolved from, the integrity and dedication that Dr. Bedzow emphasized to incoming medical students. These are all character traits. These traits are not knowledge of anatomy or skill with a scalpel. They are attitudes that colleagues hope and expect to find in any person who puts on the white coat. With experience come two more key character traits – the moderation of a work-life balance and the judgment to weigh benefits, risks, and costs.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

Early autumn is typically a quiet time for outpatient pediatricians. The school physicals are finished. The last-minute school physicals are finished. The “I forgot to get my child’s physical” physicals are finished. Respiratory syncytial virus and influenza seasons haven’t started. There is time for some self-reflection and sharpening the saw.

My reflective period each year tends to start with the unresolved “What do I want to be when I grow up?” Mind you, just because I’ve grown old doesn’t mean I’ve grown up. I never wanted to be a “grande personne” who, per Antoine de Saint-Exupéry in “Le Petit Prince,” will never understand why a minor item (Did the lamb eat the flower?) makes all the difference in the universe to a child. Awe and wonderment should remain a part of life. I enjoy reading that short story in the original French because, as my high school French vocabulary and conjugation have faded, any word I don’t recognize means exactly what my journey of a lifetime tells me it means, neither more nor less, just as Humpty Dumpty explained to Alice in Lewis Carroll’s “Through the Looking Glass.”

Along with my perennial favorites like “Le Petit Prince” and the Gettysburg Address, in this year’s folder for reflection are two essays I’ve collected this year. The first is a letter addressed from medical ethicist Ira Bedzow, PhD, to this year’s incoming class of medical students.

The essay gives advice to first-year medical students entering the profession of medicine. It talks about finding “something to say that you communicate with the whole and essence of your being.” There is lots of great counsel in the letter. It claims, “Only in a professional does one’s voice sing in harmony with one’s being. Want that for yourselves, for only a life undivided is a life of full integrity.”

I agree with the harmony part. I hesitate with the undivided part. A professional singer could be dedicated to opera but still sing in a barbershop quartet and a church choir, motivated by fun and fellowship. It is important to emphasize integrity and dedication to medical students. The letter does that well, but students must also develop a work-life balance. The ascetic life is not for everyone.

Life needs balance and moderation. I am pretty sure that Aristotle said that, but I never did spend much time studying the Classics. I use my periods of self-reflection to chart my life’s vector. I choose new skills to learn and challenges to meet. But as I grow older, I spend more time pruning those roles that no longer give me joy. Delayed gratification is an important character trait for success, but its value lessens as it becomes clear there are more days behind me than ahead.

The second essay reflects the views of Canon Brodar, a third-year medical student and divinity school graduate.

He attests to the willingness of medical trainees to accept their duties and personal risk during the crisis of the COVID-19 pandemic. He correctly points out the contributions his fellow students could make, but underestimates the negatives. During March 2020 when decisions were made to send third-year medical students home, the administrative focus was on the cost of their participation (consumption of scarce personal protective equipment) and the potential negative consequences (an additional person who might transmit the virus among patients.) Four months later, most medical students were back on the job.

Mr. Brodar’s eloquent description of duty and responsibility complement, and perhaps have evolved from, the integrity and dedication that Dr. Bedzow emphasized to incoming medical students. These are all character traits. These traits are not knowledge of anatomy or skill with a scalpel. They are attitudes that colleagues hope and expect to find in any person who puts on the white coat. With experience come two more key character traits – the moderation of a work-life balance and the judgment to weigh benefits, risks, and costs.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

Having been a bench research scientist 30 years ago, I am flabbergasted at what is and is not currently possible. In a few weeks, scientists sequenced a novel coronavirus and used the genetic sequence to select candidate molecules for a vaccine. But we still can’t reliably say how much protection a cloth mask provides. Worse yet, even if/when we could reliably quantify contagion, it isn’t clear that the public will believe us anyhow.

Thinkstock

The good news is that the public worldwide did believe scientists about the threat of a pandemic and the need to flatten the curve. Saving lives has not been about the strength of an antibiotic or the skill in managing a ventilator, but the credibility of medical scientists. The degree of acceptance was variable and subject to a variety of delays caused by regional politicians, but overall the scientific advice on social distancing has had a gigantic impact on the spread of the pandemic in the February to June time frame. The bad news is that the public’s trust in that scientific advice has waned, the willingness to accept onerous restrictions has fatigued, and the cooperation for maintaining these social changes is evaporating.

I will leave pontificating about the spread of COVID-19 to other experts in other forums. My focus is on the public’s trust in the professionalism of physicians, nurses, medical scientists, and the health care industry as a whole. That trust has been our most valuable tool in fighting the pandemic so far. There have been situations in which weaknesses in modern science have let society down during the pandemic of the century. In my February 2020 column, at the beginning of the outbreak, a month before it was declared a pandemic, when its magnitude was still unclear, I emphasized the importance of having a trusted scientific spokesperson providing timely, accurate information to the public. That, obviously, did not happen in the United States and the degree of the ensuing disaster is still to be revealed.

Scientists have made some wrong decisions about this novel threat. The advice on masks is an illustrative example. For many years, infection control nurses have insisted that medical students wear a mask to protect themselves, even if they were observing rounds from just inside the doorway of a room of a baby with bronchiolitis. The landfills are full of briefly worn surgical masks. Now the story goes: Surgical masks don’t protect staff; they protect others. Changes like that contribute to a credibility gap.

For 3 months, there was conflicting advice about the appropriateness of masks. In early March 2020, some health care workers were disciplined for wearing personal masks. Now, most scientists recommend the public use masks to reduce contagion. Significant subgroups in the U.S. population have refused, mostly to signal their contrarian politics. In June there was an anecdote of a success story from the Show Me state of Missouri, where a mask is credited for preventing an outbreak from a sick hair stylist.

It is hard to find something more reliable than an anecdote. On June 1, a meta-analysis funded by the World Health Organization was published online by Lancet. It supports the idea that masks are beneficial. It is mostly forest plots, so you can try to interpret it yourself. There were 172 observational studies in the systematic review, and the meta-analysis contains 44 relevant comparative studies and 0 randomized controlled trials. Most of those forest plots have an I2 of 75% or worse, which to me indicates that they are not much more reliable than a good anecdote. My primary conclusion was that modern academic science, in an era with a shortage of toilet paper, should convert to printing on soft tissue paper.

It is important to note that the guesstimated overall benefit of cloth masks was a relative risk of 0.30. That benefit is easily nullified if the false security of a mask causes people to congregate together in groups three times larger or for three times more minutes. N95 masks were more effective.

A different article was published in PNAS on June 11. Its senior author was awarded the Nobel Prize in Chemistry in 1995. That article touted the benefits of masks. The article is facing heavy criticism for flaws in methodology and flaws in the peer review process. A long list of signatories have joined a letter asking for the article’s retraction.

This article, when combined with the two instances of prominent articles being retracted in the prior month by the New England Journal of Medicine and The Lancet, is accumulating evidence the peer review system is not working as intended.

There are many heroes in this pandemic, from the frontline health care workers in hotspots to the grocery workers and cleaning staff. There is hope, indeed some faith, that medical scientists in the foreseeable future will provide treatments and a vaccine for this viral plague. This month, the credibility of scientists again plays a major role as communities respond to outbreaks related to reopening the economy. Let’s celebrate the victories, resolve to fix the impure system, and restore a high level of public trust in science. Lives depend on it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

Having been a bench research scientist 30 years ago, I am flabbergasted at what is and is not currently possible. In a few weeks, scientists sequenced a novel coronavirus and used the genetic sequence to select candidate molecules for a vaccine. But we still can’t reliably say how much protection a cloth mask provides. Worse yet, even if/when we could reliably quantify contagion, it isn’t clear that the public will believe us anyhow.

Thinkstock

The good news is that the public worldwide did believe scientists about the threat of a pandemic and the need to flatten the curve. Saving lives has not been about the strength of an antibiotic or the skill in managing a ventilator, but the credibility of medical scientists. The degree of acceptance was variable and subject to a variety of delays caused by regional politicians, but overall the scientific advice on social distancing has had a gigantic impact on the spread of the pandemic in the February to June time frame. The bad news is that the public’s trust in that scientific advice has waned, the willingness to accept onerous restrictions has fatigued, and the cooperation for maintaining these social changes is evaporating.

I will leave pontificating about the spread of COVID-19 to other experts in other forums. My focus is on the public’s trust in the professionalism of physicians, nurses, medical scientists, and the health care industry as a whole. That trust has been our most valuable tool in fighting the pandemic so far. There have been situations in which weaknesses in modern science have let society down during the pandemic of the century. In my February 2020 column, at the beginning of the outbreak, a month before it was declared a pandemic, when its magnitude was still unclear, I emphasized the importance of having a trusted scientific spokesperson providing timely, accurate information to the public. That, obviously, did not happen in the United States and the degree of the ensuing disaster is still to be revealed.

Scientists have made some wrong decisions about this novel threat. The advice on masks is an illustrative example. For many years, infection control nurses have insisted that medical students wear a mask to protect themselves, even if they were observing rounds from just inside the doorway of a room of a baby with bronchiolitis. The landfills are full of briefly worn surgical masks. Now the story goes: Surgical masks don’t protect staff; they protect others. Changes like that contribute to a credibility gap.

For 3 months, there was conflicting advice about the appropriateness of masks. In early March 2020, some health care workers were disciplined for wearing personal masks. Now, most scientists recommend the public use masks to reduce contagion. Significant subgroups in the U.S. population have refused, mostly to signal their contrarian politics. In June there was an anecdote of a success story from the Show Me state of Missouri, where a mask is credited for preventing an outbreak from a sick hair stylist.

It is hard to find something more reliable than an anecdote. On June 1, a meta-analysis funded by the World Health Organization was published online by Lancet. It supports the idea that masks are beneficial. It is mostly forest plots, so you can try to interpret it yourself. There were 172 observational studies in the systematic review, and the meta-analysis contains 44 relevant comparative studies and 0 randomized controlled trials. Most of those forest plots have an I2 of 75% or worse, which to me indicates that they are not much more reliable than a good anecdote. My primary conclusion was that modern academic science, in an era with a shortage of toilet paper, should convert to printing on soft tissue paper.

It is important to note that the guesstimated overall benefit of cloth masks was a relative risk of 0.30. That benefit is easily nullified if the false security of a mask causes people to congregate together in groups three times larger or for three times more minutes. N95 masks were more effective.

A different article was published in PNAS on June 11. Its senior author was awarded the Nobel Prize in Chemistry in 1995. That article touted the benefits of masks. The article is facing heavy criticism for flaws in methodology and flaws in the peer review process. A long list of signatories have joined a letter asking for the article’s retraction.

This article, when combined with the two instances of prominent articles being retracted in the prior month by the New England Journal of Medicine and The Lancet, is accumulating evidence the peer review system is not working as intended.

There are many heroes in this pandemic, from the frontline health care workers in hotspots to the grocery workers and cleaning staff. There is hope, indeed some faith, that medical scientists in the foreseeable future will provide treatments and a vaccine for this viral plague. This month, the credibility of scientists again plays a major role as communities respond to outbreaks related to reopening the economy. Let’s celebrate the victories, resolve to fix the impure system, and restore a high level of public trust in science. Lives depend on it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

Having been a bench research scientist 30 years ago, I am flabbergasted at what is and is not currently possible. In a few weeks, scientists sequenced a novel coronavirus and used the genetic sequence to select candidate molecules for a vaccine. But we still can’t reliably say how much protection a cloth mask provides. Worse yet, even if/when we could reliably quantify contagion, it isn’t clear that the public will believe us anyhow.

Thinkstock

The good news is that the public worldwide did believe scientists about the threat of a pandemic and the need to flatten the curve. Saving lives has not been about the strength of an antibiotic or the skill in managing a ventilator, but the credibility of medical scientists. The degree of acceptance was variable and subject to a variety of delays caused by regional politicians, but overall the scientific advice on social distancing has had a gigantic impact on the spread of the pandemic in the February to June time frame. The bad news is that the public’s trust in that scientific advice has waned, the willingness to accept onerous restrictions has fatigued, and the cooperation for maintaining these social changes is evaporating.

I will leave pontificating about the spread of COVID-19 to other experts in other forums. My focus is on the public’s trust in the professionalism of physicians, nurses, medical scientists, and the health care industry as a whole. That trust has been our most valuable tool in fighting the pandemic so far. There have been situations in which weaknesses in modern science have let society down during the pandemic of the century. In my February 2020 column, at the beginning of the outbreak, a month before it was declared a pandemic, when its magnitude was still unclear, I emphasized the importance of having a trusted scientific spokesperson providing timely, accurate information to the public. That, obviously, did not happen in the United States and the degree of the ensuing disaster is still to be revealed.

Scientists have made some wrong decisions about this novel threat. The advice on masks is an illustrative example. For many years, infection control nurses have insisted that medical students wear a mask to protect themselves, even if they were observing rounds from just inside the doorway of a room of a baby with bronchiolitis. The landfills are full of briefly worn surgical masks. Now the story goes: Surgical masks don’t protect staff; they protect others. Changes like that contribute to a credibility gap.

For 3 months, there was conflicting advice about the appropriateness of masks. In early March 2020, some health care workers were disciplined for wearing personal masks. Now, most scientists recommend the public use masks to reduce contagion. Significant subgroups in the U.S. population have refused, mostly to signal their contrarian politics. In June there was an anecdote of a success story from the Show Me state of Missouri, where a mask is credited for preventing an outbreak from a sick hair stylist.

It is hard to find something more reliable than an anecdote. On June 1, a meta-analysis funded by the World Health Organization was published online by Lancet. It supports the idea that masks are beneficial. It is mostly forest plots, so you can try to interpret it yourself. There were 172 observational studies in the systematic review, and the meta-analysis contains 44 relevant comparative studies and 0 randomized controlled trials. Most of those forest plots have an I2 of 75% or worse, which to me indicates that they are not much more reliable than a good anecdote. My primary conclusion was that modern academic science, in an era with a shortage of toilet paper, should convert to printing on soft tissue paper.

It is important to note that the guesstimated overall benefit of cloth masks was a relative risk of 0.30. That benefit is easily nullified if the false security of a mask causes people to congregate together in groups three times larger or for three times more minutes. N95 masks were more effective.

A different article was published in PNAS on June 11. Its senior author was awarded the Nobel Prize in Chemistry in 1995. That article touted the benefits of masks. The article is facing heavy criticism for flaws in methodology and flaws in the peer review process. A long list of signatories have joined a letter asking for the article’s retraction.

This article, when combined with the two instances of prominent articles being retracted in the prior month by the New England Journal of Medicine and The Lancet, is accumulating evidence the peer review system is not working as intended.

There are many heroes in this pandemic, from the frontline health care workers in hotspots to the grocery workers and cleaning staff. There is hope, indeed some faith, that medical scientists in the foreseeable future will provide treatments and a vaccine for this viral plague. This month, the credibility of scientists again plays a major role as communities respond to outbreaks related to reopening the economy. Let’s celebrate the victories, resolve to fix the impure system, and restore a high level of public trust in science. Lives depend on it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

COVID-19 has prompted many changes in pediatric health care. They say necessity is the mother of invention. Sometimes, necessity is the motivator for the long-past-due adoption of a previous invention, such as telemedicine for minor illnesses. And sometimes necessity reminds us about what is really important in a world of high technology.

Nicola Marfisi/AGF/Universal Images Group/Science Source

Unlike our nearly overwhelmed internal medicine, ED, and family physician colleagues, many pediatricians are in a lull that threatens the financial viability of our practices. We are postponing annual well visits. We have fewer sick visits and hospitalizations since respiratory syncytial virus (RSV) and influenza also have been reduced by social distancing. Parents are avoiding the risk of contagion in the waiting room and not bringing their children in for minor complaints. There is more telemedicine – a welcome change in financing and practice whose time has come, but was being delayed by lack of insurance coverage.

Technology has allowed clinicians to respond to the pandemic in ways that would not have been possible a few years ago. Online tools, such as subscription email lists, webinars, and electronic medical news services, provide updates when the information changes weekly on the virus’s contagiousness, asymptomatic and presymptomatic transmission, prevalence, the effectiveness of masks, and experimental treatment options. These changes have been so fast that many journal articles based on data from China were obsolete and contradicted before they appeared in print.

However, technology only helped us to more effectively do what we needed to do in the first place – come together in a world of physical distancing and work toward common goals. In many hospitals, pediatric wards were emptied by reduced RSV admissions and postponed elective surgeries. These units have been converted to accept adult patients up to age 30 or 40 years. Our med-peds colleagues quickly created webinars and online resource packages on topics pediatric hospitalists might need to care for that population. There were refresher courses on ventilator management and reminders that community pediatric hospitalists, who in the winter might have one-third of their admissions with RSV, have more experience managing viral pneumonia than the internists.

Ward teams were created with a pediatric attending and an internal medicine resident. The resident’s familiarity with the names of blood pressure medicines complemented the attending’s years of clinical judgment and bedside manner. People are stepping out of their comfort zones but initial reports from the front lines are that, with each other’s support, we’ve got this.

Mistakes in telemedicine are being made, shared, and learned from. Emergency physicians are collecting anecdotes of situations when things were missed or treatment delayed. Surgeons report seeing increased numbers of cases in which the diagnosis of appendicitis was delayed, which isn’t surprising when a pediatrician cannot lay hands on the belly. Perhaps any case in which a parent calls a second or third time should be seen in the flesh.

Some newborn nurseries are discharging mother and baby at 24 hours after birth and rediscovering what was learned about that practice, which became common in the 1990s. It works well for the vast majority of babies, but we need to be ready to detect the occasional jaundiced baby or the one where breastfeeding isn’t going well. The gray-haired pediatricians can recall those nuances.

Another key role is to help everyone process the frequent deaths during a pandemic. First, there are the families we care for. Children are losing grandparents with little warning. Parents may be overwhelmed with grief while ill themselves. That makes children vulnerable.

Our medical system in 2 months has moved heaven and earth – and significantly harmed the medical care and financial future of our children – trying to assure that every 80-year-old has the right to die while attached to a ventilator, even though only a small fraction of them will survive to discharge. Meanwhile, on the wards, visitation policies have people deteriorating and dying alone. I find this paradigm distressing and antithetical to my training.

Medicine and nursing both have long histories in which the practitioner recognized that there was little they could do to prevent the death. Their role was to compassionately guide the family through it. For some people, this connection is the most precious of the arts of medicine and nursing. We need to reexamine our values. We need to get creative. We need to involve palliative care experts and clergy with the same urgency with which we have automakers making ventilators.

Second, there are our colleagues. Pediatric caregivers, particularly trainees, rarely encounter deaths and can benefit from debriefing sessions, even short ones. There is comfort in having a colleague review the situation and say: “There was nothing you could have done.” Or even: “That minor omission did not alter the outcome.” Even when everything was done properly, deaths cause moral suffering that needs processing and healing. Even if you don’t have magic words to give, just being present aids in the healing. We are all in this, together.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

As I write this, the 2019 novel coronavirus* continues to spread, exceeding 59,000 cases and 1,300 deaths worldwide. With it spreads fear. In the modern world of social media, misinformation spreads even faster than disease.

Delpixel/Shutterstock

The news about a novel and deadly illness crowds out more substantial worries. Humans are not particularly good at assessing risk or responding rationally and consistently to it. Risk is hard to fully define. If you look up “risk” in Merriam Webster’s online dictionary, you get the simple definition of “possibility of loss or injury; peril.” If you look up risk in Wikipedia, you get 12 pages of explanation and 8 more pages of links and references.

People handle risk differently. Some people are more risk adverse than others. Some get a pleasurable thrill from risk, whether a slot machine or a parachute jump. Most people really don’t comprehend small probabilities, with tens of billions of dollars spent annually on U.S. lotteries.

Because 98% of people who get COVID-19 are recovering, this is not an extinction-level event or the zombie apocalypse. It is a major health hazard, and one where morbidity and mortality might be assuaged by an early and effective public health response, including the population’s adoption of good habits such as hand washing, cough etiquette, and staying home when ill. But fear, discrimination, and misinformation may do more damage than the virus itself.

Three key factors may help reduce the fear factor.

One key factor is accurate communication of health information to the public. This has been severely harmed in the last few years by the promotion of gossip on social media, such as Facebook, within newsfeeds without any vetting, along with a smaller component of deliberate misinformation from untraceable sources. Compare this situation with the decision in May 1988 when Surgeon General C. Everett Koop chose to snail mail a brochure on AIDS to every household in America. It was unprecedented. One element of this communication is the public’s belief that government and health care officials will responsibly and timely convey the information. There are accusations that the Chinese government initially impeded early warnings about COVID-19. Dr. Koop, to his great credit and lifesaving leadership, overcame queasiness within the Reagan administration about issues of morality and taste in discussing some of the HIV information. Alas, no similar leadership occurred in the decade of the 2010s when deaths from the opioid epidemic in the United States skyrocketed to claim more lives annually than car accidents or suicide.

A second factor is the credibility of the scientists. Antivaxxers, climate change deniers, and mercenary scientists have severely damaged that credibility of science, compared with the trust in scientists 50 years ago during the Apollo moon shot.

A third factor is perspective. Poor journalism and clickbait can focus excessively on the rare events as news. Airline crashes make the front page while fatal car accidents, claiming a hundred times more lives annually, don’t even merit a story in local media. Someone wins the lottery weekly but few pay attention to those suffering from gambling debts.

Influenza is killing many times more people than the 2019 novel coronavirus, but the news is focused on cruise ships. In the United States, influenza annually will strike tens of millions, with about 10 per 1,000 hospitalized and 0.5 per 1,000 dying. The novel coronavirus is more lethal. SARS (a coronavirus epidemic in 2003) had 8,000 cases with a mortality rate of 96 per 1,000 while the novel 2019 strain so far is killing about 20 per 1,000. That value may be an overestimate, because there may be a significant fraction of COVID-19 patients with symptoms mild enough that they do not seek medical care and do not get tested and counted.

For perspective, in 1952 the United States reported 50,000 cases of polio (meningitis or paralytic) annually with 3,000 deaths. As many as 95% of cases of poliovirus infection have no or mild symptoms and would not have been reported, so the case fatality rate estimate is skewed. In the 1950s, the United States averaged about 500,000 cases of measles per year, with about 500 deaths annually for a case fatality rate of about 1 per 1,000 in a population that was well nourished with good medical care. In malnourished children without access to modern health care, the case fatality rate can be as high as 100 per 1,000, which is why globally measles killed 142,000 people in 2018, a substantial improvement from 536,000 deaths globally in 2000, but still a leading killer of children worldwide. Vaccines had reduced the annual death toll of polio and measles in the U.S. to zero.

In comparison, in this country the annual incidences are about 70,000 overdose deaths, 50,000 suicides, and 40,000 traffic deaths.

Reassurance is the most common product sold by pediatricians. We look for low-probability, high-impact bad things. Usually we don’t find them and can reassure parents that the child will be okay. Sometimes we spot a higher-risk situation and intervene. My job is to worry professionally so that parents can worry less.

COVID-19 worries me, but irrational people worry me more. The real enemies are fear, disinformation, discrimination, and economic warfare.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

*This article was updated 2/21/2020.

As I write this, the 2019 novel coronavirus* continues to spread, exceeding 59,000 cases and 1,300 deaths worldwide. With it spreads fear. In the modern world of social media, misinformation spreads even faster than disease.

Delpixel/Shutterstock

The news about a novel and deadly illness crowds out more substantial worries. Humans are not particularly good at assessing risk or responding rationally and consistently to it. Risk is hard to fully define. If you look up “risk” in Merriam Webster’s online dictionary, you get the simple definition of “possibility of loss or injury; peril.” If you look up risk in Wikipedia, you get 12 pages of explanation and 8 more pages of links and references.

People handle risk differently. Some people are more risk adverse than others. Some get a pleasurable thrill from risk, whether a slot machine or a parachute jump. Most people really don’t comprehend small probabilities, with tens of billions of dollars spent annually on U.S. lotteries.

Because 98% of people who get COVID-19 are recovering, this is not an extinction-level event or the zombie apocalypse. It is a major health hazard, and one where morbidity and mortality might be assuaged by an early and effective public health response, including the population’s adoption of good habits such as hand washing, cough etiquette, and staying home when ill. But fear, discrimination, and misinformation may do more damage than the virus itself.

Three key factors may help reduce the fear factor.

One key factor is accurate communication of health information to the public. This has been severely harmed in the last few years by the promotion of gossip on social media, such as Facebook, within newsfeeds without any vetting, along with a smaller component of deliberate misinformation from untraceable sources. Compare this situation with the decision in May 1988 when Surgeon General C. Everett Koop chose to snail mail a brochure on AIDS to every household in America. It was unprecedented. One element of this communication is the public’s belief that government and health care officials will responsibly and timely convey the information. There are accusations that the Chinese government initially impeded early warnings about COVID-19. Dr. Koop, to his great credit and lifesaving leadership, overcame queasiness within the Reagan administration about issues of morality and taste in discussing some of the HIV information. Alas, no similar leadership occurred in the decade of the 2010s when deaths from the opioid epidemic in the United States skyrocketed to claim more lives annually than car accidents or suicide.

A second factor is the credibility of the scientists. Antivaxxers, climate change deniers, and mercenary scientists have severely damaged that credibility of science, compared with the trust in scientists 50 years ago during the Apollo moon shot.

A third factor is perspective. Poor journalism and clickbait can focus excessively on the rare events as news. Airline crashes make the front page while fatal car accidents, claiming a hundred times more lives annually, don’t even merit a story in local media. Someone wins the lottery weekly but few pay attention to those suffering from gambling debts.

Influenza is killing many times more people than the 2019 novel coronavirus, but the news is focused on cruise ships. In the United States, influenza annually will strike tens of millions, with about 10 per 1,000 hospitalized and 0.5 per 1,000 dying. The novel coronavirus is more lethal. SARS (a coronavirus epidemic in 2003) had 8,000 cases with a mortality rate of 96 per 1,000 while the novel 2019 strain so far is killing about 20 per 1,000. That value may be an overestimate, because there may be a significant fraction of COVID-19 patients with symptoms mild enough that they do not seek medical care and do not get tested and counted.

For perspective, in 1952 the United States reported 50,000 cases of polio (meningitis or paralytic) annually with 3,000 deaths. As many as 95% of cases of poliovirus infection have no or mild symptoms and would not have been reported, so the case fatality rate estimate is skewed. In the 1950s, the United States averaged about 500,000 cases of measles per year, with about 500 deaths annually for a case fatality rate of about 1 per 1,000 in a population that was well nourished with good medical care. In malnourished children without access to modern health care, the case fatality rate can be as high as 100 per 1,000, which is why globally measles killed 142,000 people in 2018, a substantial improvement from 536,000 deaths globally in 2000, but still a leading killer of children worldwide. Vaccines had reduced the annual death toll of polio and measles in the U.S. to zero.

In comparison, in this country the annual incidences are about 70,000 overdose deaths, 50,000 suicides, and 40,000 traffic deaths.

Reassurance is the most common product sold by pediatricians. We look for low-probability, high-impact bad things. Usually we don’t find them and can reassure parents that the child will be okay. Sometimes we spot a higher-risk situation and intervene. My job is to worry professionally so that parents can worry less.

COVID-19 worries me, but irrational people worry me more. The real enemies are fear, disinformation, discrimination, and economic warfare.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

*This article was updated 2/21/2020.

As I write this, the 2019 novel coronavirus* continues to spread, exceeding 59,000 cases and 1,300 deaths worldwide. With it spreads fear. In the modern world of social media, misinformation spreads even faster than disease.

Delpixel/Shutterstock

The news about a novel and deadly illness crowds out more substantial worries. Humans are not particularly good at assessing risk or responding rationally and consistently to it. Risk is hard to fully define. If you look up “risk” in Merriam Webster’s online dictionary, you get the simple definition of “possibility of loss or injury; peril.” If you look up risk in Wikipedia, you get 12 pages of explanation and 8 more pages of links and references.

People handle risk differently. Some people are more risk adverse than others. Some get a pleasurable thrill from risk, whether a slot machine or a parachute jump. Most people really don’t comprehend small probabilities, with tens of billions of dollars spent annually on U.S. lotteries.

Because 98% of people who get COVID-19 are recovering, this is not an extinction-level event or the zombie apocalypse. It is a major health hazard, and one where morbidity and mortality might be assuaged by an early and effective public health response, including the population’s adoption of good habits such as hand washing, cough etiquette, and staying home when ill. But fear, discrimination, and misinformation may do more damage than the virus itself.

Three key factors may help reduce the fear factor.

One key factor is accurate communication of health information to the public. This has been severely harmed in the last few years by the promotion of gossip on social media, such as Facebook, within newsfeeds without any vetting, along with a smaller component of deliberate misinformation from untraceable sources. Compare this situation with the decision in May 1988 when Surgeon General C. Everett Koop chose to snail mail a brochure on AIDS to every household in America. It was unprecedented. One element of this communication is the public’s belief that government and health care officials will responsibly and timely convey the information. There are accusations that the Chinese government initially impeded early warnings about COVID-19. Dr. Koop, to his great credit and lifesaving leadership, overcame queasiness within the Reagan administration about issues of morality and taste in discussing some of the HIV information. Alas, no similar leadership occurred in the decade of the 2010s when deaths from the opioid epidemic in the United States skyrocketed to claim more lives annually than car accidents or suicide.

A second factor is the credibility of the scientists. Antivaxxers, climate change deniers, and mercenary scientists have severely damaged that credibility of science, compared with the trust in scientists 50 years ago during the Apollo moon shot.

A third factor is perspective. Poor journalism and clickbait can focus excessively on the rare events as news. Airline crashes make the front page while fatal car accidents, claiming a hundred times more lives annually, don’t even merit a story in local media. Someone wins the lottery weekly but few pay attention to those suffering from gambling debts.

Influenza is killing many times more people than the 2019 novel coronavirus, but the news is focused on cruise ships. In the United States, influenza annually will strike tens of millions, with about 10 per 1,000 hospitalized and 0.5 per 1,000 dying. The novel coronavirus is more lethal. SARS (a coronavirus epidemic in 2003) had 8,000 cases with a mortality rate of 96 per 1,000 while the novel 2019 strain so far is killing about 20 per 1,000. That value may be an overestimate, because there may be a significant fraction of COVID-19 patients with symptoms mild enough that they do not seek medical care and do not get tested and counted.

For perspective, in 1952 the United States reported 50,000 cases of polio (meningitis or paralytic) annually with 3,000 deaths. As many as 95% of cases of poliovirus infection have no or mild symptoms and would not have been reported, so the case fatality rate estimate is skewed. In the 1950s, the United States averaged about 500,000 cases of measles per year, with about 500 deaths annually for a case fatality rate of about 1 per 1,000 in a population that was well nourished with good medical care. In malnourished children without access to modern health care, the case fatality rate can be as high as 100 per 1,000, which is why globally measles killed 142,000 people in 2018, a substantial improvement from 536,000 deaths globally in 2000, but still a leading killer of children worldwide. Vaccines had reduced the annual death toll of polio and measles in the U.S. to zero.

In comparison, in this country the annual incidences are about 70,000 overdose deaths, 50,000 suicides, and 40,000 traffic deaths.

Reassurance is the most common product sold by pediatricians. We look for low-probability, high-impact bad things. Usually we don’t find them and can reassure parents that the child will be okay. Sometimes we spot a higher-risk situation and intervene. My job is to worry professionally so that parents can worry less.

COVID-19 worries me, but irrational people worry me more. The real enemies are fear, disinformation, discrimination, and economic warfare.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

*This article was updated 2/21/2020.

Medicine is a rewarding but demanding field. Part of being a professional is handling the stresses of the job. That ability is as important as tying strong horizontal mattress sutures, choosing correct antibiotics to treat staph, and gently breaking bad news.

doomu/Thinkstock

The divorce and suicide rate among physicians are evidence that many physicians handle stress poorly. Our rates of depression, burnout, alcoholism, and substance abuse are further evidence of the suffering caused by unmitigated stress. It is endemic and destructive, harming physicians, their loved ones, and their patients. While this situation has long been true, in the past decade its importance has become better recognized. Some scholars have added physician wellness or fulfillment as a fourth aim of medical care to complement the triple aims of patient outcomes, consumer experience, and financial stewardship.

The sources of stress can be either external or internal. Internally, many physicians feel torn between competing professional roles. Recently one fellow in pediatric intensive care wrote an insightful reflective essay about two conflicting roles (“Virtue and Suffering: Where the Personal and Professional Collide,” Lauren Rissman, MD. reflectivemeded.org). One side is the potential benefits of technology and modern medical interventions. The other side is compassion and knowing when to say enough. Finding that balance – or boundary – or mixture is difficult. Even more difficult is helping patients/parents who are struggling with those choices.

Some old models of the doctor-patient relationship insisted on an emotional detachment to promote objectivity. This often is paired with using nondirective counseling. The admonishment for a physician to be nondirective comes up in end-of-life care choices in the ICU. It comes up in genetic counseling, particularly in the prenatal time frame, and when I do ethics consults requiring values clarification and mediation. But I also have found times during shared decision making when the model of a fully informed consumer choice is not valid. There are situations in which a paradigm of emotional detachment impairs the ability to convey empathy, compassion, and presence. Being detached also may prevent the moments of personal connection between doctor and patient that are the intangible rewards of the vocation. A good physician knows how to choose among these idealized models. It requires being genuine when employing a diverse bag of bedside tools.

High technology and highly invasive care pose dilemmas in assessing outcomes, minimizing suffering, and ensuring financial stewardship. When one addresses those different types of dilemmas happening simultaneously, the initial approach can be to separate the different influences into separate vectors. But when one does this on a regular basis, it fractures one’s self-image. To survive and flourish, the physician juggling these competing, conflicting goals must shun the split personality and seek to live as an integrated moral agent. This integration is not achieved by working harder or longer or even smarter. It requires time and effort directed to self-reflection. When pediatric ethicists get together at conferences, I notice that about one-half of them are neonatal ICU docs and one-quarter are pediatric ICU docs. Many view their work in ethics as a survival mechanism. We all are looking for answers to questions we may not be able to fully articulate.

In this short column I will not endeavor to offer a neat package of advice on how to achieve being whole. Dr. Rissman in her essay is just starting her career while I’m nearing the end of mine. It is a lifelong process to integrate oneself rather than exist in turmoil. It truly is a journey, not a destination. After a career dedicated to considering technology, compassion, and costs, I know there are no simple solutions. I also know that it is important to keep seeking better answers.

To encourage group discussion of ethical problems, I have heard facilitators say that there are no right and wrong answers. I strongly disagree. In ethics, there often is more than one correct answer. Ethicists can write books on why one right answer is slightly better than another right answer for a particular individual or population. We live for debates over such minutiae. In the real world of medical ethics, there also are definitely wrong answers.

The difference between medical ethics and philosophy is that, when all the talking is done, in medical ethics something happens. That makes a difference. Professional athletes know the importance of recovery after an intense workout. Muscles have accumulated microscopic tears that must heal. Professional physicians must develop a personal regimen of caring for overexertion of their own emotional and moral/spiritual muscles in order to remain whole.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

Medicine is a rewarding but demanding field. Part of being a professional is handling the stresses of the job. That ability is as important as tying strong horizontal mattress sutures, choosing correct antibiotics to treat staph, and gently breaking bad news.

doomu/Thinkstock

The divorce and suicide rate among physicians are evidence that many physicians handle stress poorly. Our rates of depression, burnout, alcoholism, and substance abuse are further evidence of the suffering caused by unmitigated stress. It is endemic and destructive, harming physicians, their loved ones, and their patients. While this situation has long been true, in the past decade its importance has become better recognized. Some scholars have added physician wellness or fulfillment as a fourth aim of medical care to complement the triple aims of patient outcomes, consumer experience, and financial stewardship.

The sources of stress can be either external or internal. Internally, many physicians feel torn between competing professional roles. Recently one fellow in pediatric intensive care wrote an insightful reflective essay about two conflicting roles (“Virtue and Suffering: Where the Personal and Professional Collide,” Lauren Rissman, MD. reflectivemeded.org). One side is the potential benefits of technology and modern medical interventions. The other side is compassion and knowing when to say enough. Finding that balance – or boundary – or mixture is difficult. Even more difficult is helping patients/parents who are struggling with those choices.

Some old models of the doctor-patient relationship insisted on an emotional detachment to promote objectivity. This often is paired with using nondirective counseling. The admonishment for a physician to be nondirective comes up in end-of-life care choices in the ICU. It comes up in genetic counseling, particularly in the prenatal time frame, and when I do ethics consults requiring values clarification and mediation. But I also have found times during shared decision making when the model of a fully informed consumer choice is not valid. There are situations in which a paradigm of emotional detachment impairs the ability to convey empathy, compassion, and presence. Being detached also may prevent the moments of personal connection between doctor and patient that are the intangible rewards of the vocation. A good physician knows how to choose among these idealized models. It requires being genuine when employing a diverse bag of bedside tools.

High technology and highly invasive care pose dilemmas in assessing outcomes, minimizing suffering, and ensuring financial stewardship. When one addresses those different types of dilemmas happening simultaneously, the initial approach can be to separate the different influences into separate vectors. But when one does this on a regular basis, it fractures one’s self-image. To survive and flourish, the physician juggling these competing, conflicting goals must shun the split personality and seek to live as an integrated moral agent. This integration is not achieved by working harder or longer or even smarter. It requires time and effort directed to self-reflection. When pediatric ethicists get together at conferences, I notice that about one-half of them are neonatal ICU docs and one-quarter are pediatric ICU docs. Many view their work in ethics as a survival mechanism. We all are looking for answers to questions we may not be able to fully articulate.

In this short column I will not endeavor to offer a neat package of advice on how to achieve being whole. Dr. Rissman in her essay is just starting her career while I’m nearing the end of mine. It is a lifelong process to integrate oneself rather than exist in turmoil. It truly is a journey, not a destination. After a career dedicated to considering technology, compassion, and costs, I know there are no simple solutions. I also know that it is important to keep seeking better answers.

To encourage group discussion of ethical problems, I have heard facilitators say that there are no right and wrong answers. I strongly disagree. In ethics, there often is more than one correct answer. Ethicists can write books on why one right answer is slightly better than another right answer for a particular individual or population. We live for debates over such minutiae. In the real world of medical ethics, there also are definitely wrong answers.

The difference between medical ethics and philosophy is that, when all the talking is done, in medical ethics something happens. That makes a difference. Professional athletes know the importance of recovery after an intense workout. Muscles have accumulated microscopic tears that must heal. Professional physicians must develop a personal regimen of caring for overexertion of their own emotional and moral/spiritual muscles in order to remain whole.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

Medicine is a rewarding but demanding field. Part of being a professional is handling the stresses of the job. That ability is as important as tying strong horizontal mattress sutures, choosing correct antibiotics to treat staph, and gently breaking bad news.

doomu/Thinkstock

The divorce and suicide rate among physicians are evidence that many physicians handle stress poorly. Our rates of depression, burnout, alcoholism, and substance abuse are further evidence of the suffering caused by unmitigated stress. It is endemic and destructive, harming physicians, their loved ones, and their patients. While this situation has long been true, in the past decade its importance has become better recognized. Some scholars have added physician wellness or fulfillment as a fourth aim of medical care to complement the triple aims of patient outcomes, consumer experience, and financial stewardship.

The sources of stress can be either external or internal. Internally, many physicians feel torn between competing professional roles. Recently one fellow in pediatric intensive care wrote an insightful reflective essay about two conflicting roles (“Virtue and Suffering: Where the Personal and Professional Collide,” Lauren Rissman, MD. reflectivemeded.org). One side is the potential benefits of technology and modern medical interventions. The other side is compassion and knowing when to say enough. Finding that balance – or boundary – or mixture is difficult. Even more difficult is helping patients/parents who are struggling with those choices.

Some old models of the doctor-patient relationship insisted on an emotional detachment to promote objectivity. This often is paired with using nondirective counseling. The admonishment for a physician to be nondirective comes up in end-of-life care choices in the ICU. It comes up in genetic counseling, particularly in the prenatal time frame, and when I do ethics consults requiring values clarification and mediation. But I also have found times during shared decision making when the model of a fully informed consumer choice is not valid. There are situations in which a paradigm of emotional detachment impairs the ability to convey empathy, compassion, and presence. Being detached also may prevent the moments of personal connection between doctor and patient that are the intangible rewards of the vocation. A good physician knows how to choose among these idealized models. It requires being genuine when employing a diverse bag of bedside tools.

High technology and highly invasive care pose dilemmas in assessing outcomes, minimizing suffering, and ensuring financial stewardship. When one addresses those different types of dilemmas happening simultaneously, the initial approach can be to separate the different influences into separate vectors. But when one does this on a regular basis, it fractures one’s self-image. To survive and flourish, the physician juggling these competing, conflicting goals must shun the split personality and seek to live as an integrated moral agent. This integration is not achieved by working harder or longer or even smarter. It requires time and effort directed to self-reflection. When pediatric ethicists get together at conferences, I notice that about one-half of them are neonatal ICU docs and one-quarter are pediatric ICU docs. Many view their work in ethics as a survival mechanism. We all are looking for answers to questions we may not be able to fully articulate.

In this short column I will not endeavor to offer a neat package of advice on how to achieve being whole. Dr. Rissman in her essay is just starting her career while I’m nearing the end of mine. It is a lifelong process to integrate oneself rather than exist in turmoil. It truly is a journey, not a destination. After a career dedicated to considering technology, compassion, and costs, I know there are no simple solutions. I also know that it is important to keep seeking better answers.

To encourage group discussion of ethical problems, I have heard facilitators say that there are no right and wrong answers. I strongly disagree. In ethics, there often is more than one correct answer. Ethicists can write books on why one right answer is slightly better than another right answer for a particular individual or population. We live for debates over such minutiae. In the real world of medical ethics, there also are definitely wrong answers.

The difference between medical ethics and philosophy is that, when all the talking is done, in medical ethics something happens. That makes a difference. Professional athletes know the importance of recovery after an intense workout. Muscles have accumulated microscopic tears that must heal. Professional physicians must develop a personal regimen of caring for overexertion of their own emotional and moral/spiritual muscles in order to remain whole.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

As I look back, there have been many changes during my 25 years of clinical practice. I always assumed there would be advancements in medical research during my career. I expected those advancements to produce progress rather than a random walk.

One area of positive change has been the recommendations for safe sleep practices for young infants. The Back to Sleep program of the mid 1990s reversed prior advice. It recommended that babies should sleep on their backs to avoid accidental suffocation. Prior advice had been that they should sleep on their stomachs to avoid aspiration. The new advice cut infant deaths by 50%.

Over the years, treatment of gastroesophageal reflux has significantly changed. Polysomnograms are ordered much less frequently. Medications to reduce stomach acid have been associated with side effects and now are discouraged. Raising the head of the crib was common advice in 2000s that was contradicted in the 2010s. For 2 decades I wrote orders in the hospital to elevate the head of the crib. More frequently, the nurses did it without my orders whenever they found a spitty baby.

In May 2019, there was a product recall of inclined infant sleepers. The Fisher-Price Rock ‘n Play was one product recalled; 4.7 million of these were sold in the United States in the past 10 years. Because they are used only by infants, and because there are about 4 million births per year in the United States, there are enough of these items stored in basements and garages for every infant to have one.

Investigative reporting by the Washington Post yielded an article highly critical of the product and the way it was originally created and designed. There is outrage in the author’s description of events. Because I have degrees in both engineering and pediatric medicine, I reviewed his assertions and tried to compare his ideal of the medical research world with my reality.

There are 3,600 infant deaths per year in the United States attributed to SUID/SIDS (sudden unexplained infant death/sudden infant death syndrome). From that perspective, I don’t know what 30 deaths in a decade associated with the sleeper really means. There is a high potential for recall bias and confirmation bias. It doesn’t surprise me that there was a delay in assigning blame to an ubiquitous consumer product. The article assumes that medical opinion is monolithic and synchronized rather than undergoing a diffusion of innovation, as described by Everett M. Rogers. Sorting out who knew what and when they knew it will take the courts many years.

Some of my columns earlier this year have appraised medical information in social media, and particularly on Facebook, as being harmfully unreliable. I find when I appraise the quality of medical information in peer-reviewed articles in reputable journals, its reliability isn’t good either.

An example of the unreliability of modern medical research was documented in an article in Hospital Pediatrics in July 2019.

The authors were performing a meta-analysis to determine whether the use of respiratory viral (RV) detection tests are helpful in reducing length of stay or reducing unnecessary antibiotic use. To me, that is a much simpler issue, scientifically, than safe sleep practices. The authors found 23 relevant studies that met their criteria for inclusion. Their overall conclusion was that the quality of the studies, the heterogeneity of the studies, and the statistically significant but contradictory results between the studies made it impossible to prove RV testing is beneficial. However, as I read the article, they cannot – for a litany of reasons – rule out such a benefit. Twenty three published articles in total yielded no reliable medical knowledge.

RV testing already has been widely adopted, particularly in emergency rooms. It is expensive. Clinical guidelines discourage RV testing but those guidelines are based on RV testing in the 2003-2006 time frame, which is obsolete technology. The author of the article on the infant sleepers expressed shock at what he considered to be inadequate medical research supporting the development of the inclined infant sleeper. RV testing is a product in widespread use, with lots of research, and has no better proof of efficacy or safety.

I expected, when I first started practice, that when I was older and grayer I would look back and recall many advances. I anticipated my recall would be of fond memories and of many patients helped. What I didn’t expect was so much of the advice that I provided to be wrong. Perhaps my medical education and parts of the academic research system should be subject to a product recall.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

As I look back, there have been many changes during my 25 years of clinical practice. I always assumed there would be advancements in medical research during my career. I expected those advancements to produce progress rather than a random walk.

One area of positive change has been the recommendations for safe sleep practices for young infants. The Back to Sleep program of the mid 1990s reversed prior advice. It recommended that babies should sleep on their backs to avoid accidental suffocation. Prior advice had been that they should sleep on their stomachs to avoid aspiration. The new advice cut infant deaths by 50%.

Over the years, treatment of gastroesophageal reflux has significantly changed. Polysomnograms are ordered much less frequently. Medications to reduce stomach acid have been associated with side effects and now are discouraged. Raising the head of the crib was common advice in 2000s that was contradicted in the 2010s. For 2 decades I wrote orders in the hospital to elevate the head of the crib. More frequently, the nurses did it without my orders whenever they found a spitty baby.

In May 2019, there was a product recall of inclined infant sleepers. The Fisher-Price Rock ‘n Play was one product recalled; 4.7 million of these were sold in the United States in the past 10 years. Because they are used only by infants, and because there are about 4 million births per year in the United States, there are enough of these items stored in basements and garages for every infant to have one.

Investigative reporting by the Washington Post yielded an article highly critical of the product and the way it was originally created and designed. There is outrage in the author’s description of events. Because I have degrees in both engineering and pediatric medicine, I reviewed his assertions and tried to compare his ideal of the medical research world with my reality.

There are 3,600 infant deaths per year in the United States attributed to SUID/SIDS (sudden unexplained infant death/sudden infant death syndrome). From that perspective, I don’t know what 30 deaths in a decade associated with the sleeper really means. There is a high potential for recall bias and confirmation bias. It doesn’t surprise me that there was a delay in assigning blame to an ubiquitous consumer product. The article assumes that medical opinion is monolithic and synchronized rather than undergoing a diffusion of innovation, as described by Everett M. Rogers. Sorting out who knew what and when they knew it will take the courts many years.

Some of my columns earlier this year have appraised medical information in social media, and particularly on Facebook, as being harmfully unreliable. I find when I appraise the quality of medical information in peer-reviewed articles in reputable journals, its reliability isn’t good either.

An example of the unreliability of modern medical research was documented in an article in Hospital Pediatrics in July 2019.

The authors were performing a meta-analysis to determine whether the use of respiratory viral (RV) detection tests are helpful in reducing length of stay or reducing unnecessary antibiotic use. To me, that is a much simpler issue, scientifically, than safe sleep practices. The authors found 23 relevant studies that met their criteria for inclusion. Their overall conclusion was that the quality of the studies, the heterogeneity of the studies, and the statistically significant but contradictory results between the studies made it impossible to prove RV testing is beneficial. However, as I read the article, they cannot – for a litany of reasons – rule out such a benefit. Twenty three published articles in total yielded no reliable medical knowledge.

RV testing already has been widely adopted, particularly in emergency rooms. It is expensive. Clinical guidelines discourage RV testing but those guidelines are based on RV testing in the 2003-2006 time frame, which is obsolete technology. The author of the article on the infant sleepers expressed shock at what he considered to be inadequate medical research supporting the development of the inclined infant sleeper. RV testing is a product in widespread use, with lots of research, and has no better proof of efficacy or safety.

I expected, when I first started practice, that when I was older and grayer I would look back and recall many advances. I anticipated my recall would be of fond memories and of many patients helped. What I didn’t expect was so much of the advice that I provided to be wrong. Perhaps my medical education and parts of the academic research system should be subject to a product recall.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

As I look back, there have been many changes during my 25 years of clinical practice. I always assumed there would be advancements in medical research during my career. I expected those advancements to produce progress rather than a random walk.

One area of positive change has been the recommendations for safe sleep practices for young infants. The Back to Sleep program of the mid 1990s reversed prior advice. It recommended that babies should sleep on their backs to avoid accidental suffocation. Prior advice had been that they should sleep on their stomachs to avoid aspiration. The new advice cut infant deaths by 50%.

Over the years, treatment of gastroesophageal reflux has significantly changed. Polysomnograms are ordered much less frequently. Medications to reduce stomach acid have been associated with side effects and now are discouraged. Raising the head of the crib was common advice in 2000s that was contradicted in the 2010s. For 2 decades I wrote orders in the hospital to elevate the head of the crib. More frequently, the nurses did it without my orders whenever they found a spitty baby.

In May 2019, there was a product recall of inclined infant sleepers. The Fisher-Price Rock ‘n Play was one product recalled; 4.7 million of these were sold in the United States in the past 10 years. Because they are used only by infants, and because there are about 4 million births per year in the United States, there are enough of these items stored in basements and garages for every infant to have one.

Investigative reporting by the Washington Post yielded an article highly critical of the product and the way it was originally created and designed. There is outrage in the author’s description of events. Because I have degrees in both engineering and pediatric medicine, I reviewed his assertions and tried to compare his ideal of the medical research world with my reality.

There are 3,600 infant deaths per year in the United States attributed to SUID/SIDS (sudden unexplained infant death/sudden infant death syndrome). From that perspective, I don’t know what 30 deaths in a decade associated with the sleeper really means. There is a high potential for recall bias and confirmation bias. It doesn’t surprise me that there was a delay in assigning blame to an ubiquitous consumer product. The article assumes that medical opinion is monolithic and synchronized rather than undergoing a diffusion of innovation, as described by Everett M. Rogers. Sorting out who knew what and when they knew it will take the courts many years.

Some of my columns earlier this year have appraised medical information in social media, and particularly on Facebook, as being harmfully unreliable. I find when I appraise the quality of medical information in peer-reviewed articles in reputable journals, its reliability isn’t good either.

An example of the unreliability of modern medical research was documented in an article in Hospital Pediatrics in July 2019.

The authors were performing a meta-analysis to determine whether the use of respiratory viral (RV) detection tests are helpful in reducing length of stay or reducing unnecessary antibiotic use. To me, that is a much simpler issue, scientifically, than safe sleep practices. The authors found 23 relevant studies that met their criteria for inclusion. Their overall conclusion was that the quality of the studies, the heterogeneity of the studies, and the statistically significant but contradictory results between the studies made it impossible to prove RV testing is beneficial. However, as I read the article, they cannot – for a litany of reasons – rule out such a benefit. Twenty three published articles in total yielded no reliable medical knowledge.

RV testing already has been widely adopted, particularly in emergency rooms. It is expensive. Clinical guidelines discourage RV testing but those guidelines are based on RV testing in the 2003-2006 time frame, which is obsolete technology. The author of the article on the infant sleepers expressed shock at what he considered to be inadequate medical research supporting the development of the inclined infant sleeper. RV testing is a product in widespread use, with lots of research, and has no better proof of efficacy or safety.

I expected, when I first started practice, that when I was older and grayer I would look back and recall many advances. I anticipated my recall would be of fond memories and of many patients helped. What I didn’t expect was so much of the advice that I provided to be wrong. Perhaps my medical education and parts of the academic research system should be subject to a product recall.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

A well-formed conscience is an important part of being a physician. This particularly is true for those who consider medicine a vocation, or a calling, rather than just a job.

Juanmonino/Getty Images

On May 2, 2019, the Department of Health and Human Services made public a 440-page document known as the Final Conscience Rule.¹ It isn’t quite final. And the state of California already is suing to stop it.² But the document represents the culmination of years of legal wrangling over whether physicians are allowed to have consciences or whether they must function as automatons providing any legally permitted care that a patient might demand. This comprehensive document provides a history of the issues, but was written in dense legalese, as if it expected to be answering challenges in court.

The short answer in the United States is that religious liberty continues to triumph over editorials in the New England Journal of Medicine. Consciences are allowed. The Final Conscience Rule begins with “The United States has a long history of providing protections in health care for individuals and entities on the basis of religious beliefs or moral convictions.” That history includes the Religious Freedom and Restoration Act of 1993.³ RFRA was introduced into the Senate by Sen. Ted Kennedy (D-Mass.), a bastion of liberal health care policies, and passed by a 97-3 vote. It was introduced into the House by then-Rep. Chuck Schumer (D-N.Y.) and passed by a unanimous voice vote. RFRA is not the invention of Republican fundamentalists.

For my colleagues in Canada, the Ontario Court of Appeals (ONCA, the highest provincial court) decided on May 15, 2019, that the opposite situation is the law in Canada. A recent Ontario law concerning medical assistance in dying (also known as physician-assisted suicide) requires Ontario physicians to either provide the assistance when requested or to make an effective referral, defined as “a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency.” Some Canadian physicians objected to this requirement as a violation of their consciences and their Hippocratic Oaths. They lost. The ONCA decision is 74 readable, double-spaced pages and spells out the ethics and legal principles. In summary, the ONCA said the policies on requiring an effective referral “strike a reasonable balance between patients’ interests and physicians’ Charter-protected religious freedom. In short, they are reasonable limits prescribed by law that are demonstrably justified in a free and democratic society.”⁴

The California physician-assisted dying law, known as the End of Life Option Act, which became effective in 2016, has policies which are very different from the Ontario policies. The California law has clear protections for the consciences of physicians. The law empowers them to avoid being compelled or coerced into cooperating with these deaths. “Participation in activities authorized pursuant to this part shall be voluntary. … A person or entity that elects, for reasons of conscience, morality, or ethics, not to engage in activities authorized pursuant to this part is not required to take any action in support of an individual’s decision under this part.”⁵ If it seems strange that California would strongly protect conscience with its own statute but challenge the new federal regulations, welcome to tribal politics.

The point is that the role of physicians in abortion, physician aid in dying, and other controversial practices is not going to be decided by philosophical discussions about the ideal scope and purpose of medicine. Compromises are involved that reflect the values of society. Canada is more anticlerical than the United States, and Ontario chose a different path. French culture is even more extreme. Recently, mayors in two towns in France told their elementary schools to stop offering alternative entrées on days when pork was served for hot lunches. Secular schools were not to provide accommodation for students (Muslim and Jewish) who religiously objected to pork. Since the French Revolution, the emphasis is on assimilation and laïcité (France’s principle of secularism in public affairs). The cathedral Notre-Dame de Paris – recently damaged by fire – is owned by the state, not the Catholic Church. The United States has a different history and culture. It has supported religious liberty and reasonable accommodations. That is the loving thing to do. But as a reminder, the Peace of Westphalia in 1648, which ended European religious wars between Protestants and Catholics, was not a result of enlightened thinking and agapeic love. The fighting parties looked in the abyss of mutual annihilation and opted for coexistence instead.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

References

1. Department of Health and Human Services, “HHS Announces Final Conscience Rule Protecting Health Care Entities and Individuals,” May 2, 2019.

2. “California sues Trump administration over ‘conscience rule’ that could limit abortions,” Los Angeles Times, May 21, 2019.

3. Wikipedia, “Religious Freedom Restoration Act of 1993”

4. Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393.

5. California Assembly Bill No. 15, End of Life Option Act.

The article was updated on June 21, 2019.

A well-formed conscience is an important part of being a physician. This particularly is true for those who consider medicine a vocation, or a calling, rather than just a job.

Juanmonino/Getty Images

On May 2, 2019, the Department of Health and Human Services made public a 440-page document known as the Final Conscience Rule.¹ It isn’t quite final. And the state of California already is suing to stop it.² But the document represents the culmination of years of legal wrangling over whether physicians are allowed to have consciences or whether they must function as automatons providing any legally permitted care that a patient might demand. This comprehensive document provides a history of the issues, but was written in dense legalese, as if it expected to be answering challenges in court.

The short answer in the United States is that religious liberty continues to triumph over editorials in the New England Journal of Medicine. Consciences are allowed. The Final Conscience Rule begins with “The United States has a long history of providing protections in health care for individuals and entities on the basis of religious beliefs or moral convictions.” That history includes the Religious Freedom and Restoration Act of 1993.³ RFRA was introduced into the Senate by Sen. Ted Kennedy (D-Mass.), a bastion of liberal health care policies, and passed by a 97-3 vote. It was introduced into the House by then-Rep. Chuck Schumer (D-N.Y.) and passed by a unanimous voice vote. RFRA is not the invention of Republican fundamentalists.

For my colleagues in Canada, the Ontario Court of Appeals (ONCA, the highest provincial court) decided on May 15, 2019, that the opposite situation is the law in Canada. A recent Ontario law concerning medical assistance in dying (also known as physician-assisted suicide) requires Ontario physicians to either provide the assistance when requested or to make an effective referral, defined as “a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency.” Some Canadian physicians objected to this requirement as a violation of their consciences and their Hippocratic Oaths. They lost. The ONCA decision is 74 readable, double-spaced pages and spells out the ethics and legal principles. In summary, the ONCA said the policies on requiring an effective referral “strike a reasonable balance between patients’ interests and physicians’ Charter-protected religious freedom. In short, they are reasonable limits prescribed by law that are demonstrably justified in a free and democratic society.”⁴

The California physician-assisted dying law, known as the End of Life Option Act, which became effective in 2016, has policies which are very different from the Ontario policies. The California law has clear protections for the consciences of physicians. The law empowers them to avoid being compelled or coerced into cooperating with these deaths. “Participation in activities authorized pursuant to this part shall be voluntary. … A person or entity that elects, for reasons of conscience, morality, or ethics, not to engage in activities authorized pursuant to this part is not required to take any action in support of an individual’s decision under this part.”⁵ If it seems strange that California would strongly protect conscience with its own statute but challenge the new federal regulations, welcome to tribal politics.

The point is that the role of physicians in abortion, physician aid in dying, and other controversial practices is not going to be decided by philosophical discussions about the ideal scope and purpose of medicine. Compromises are involved that reflect the values of society. Canada is more anticlerical than the United States, and Ontario chose a different path. French culture is even more extreme. Recently, mayors in two towns in France told their elementary schools to stop offering alternative entrées on days when pork was served for hot lunches. Secular schools were not to provide accommodation for students (Muslim and Jewish) who religiously objected to pork. Since the French Revolution, the emphasis is on assimilation and laïcité (France’s principle of secularism in public affairs). The cathedral Notre-Dame de Paris – recently damaged by fire – is owned by the state, not the Catholic Church. The United States has a different history and culture. It has supported religious liberty and reasonable accommodations. That is the loving thing to do. But as a reminder, the Peace of Westphalia in 1648, which ended European religious wars between Protestants and Catholics, was not a result of enlightened thinking and agapeic love. The fighting parties looked in the abyss of mutual annihilation and opted for coexistence instead.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

References

1. Department of Health and Human Services, “HHS Announces Final Conscience Rule Protecting Health Care Entities and Individuals,” May 2, 2019.

2. “California sues Trump administration over ‘conscience rule’ that could limit abortions,” Los Angeles Times, May 21, 2019.

3. Wikipedia, “Religious Freedom Restoration Act of 1993”

4. Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393.

5. California Assembly Bill No. 15, End of Life Option Act.

The article was updated on June 21, 2019.

A well-formed conscience is an important part of being a physician. This particularly is true for those who consider medicine a vocation, or a calling, rather than just a job.

Juanmonino/Getty Images

On May 2, 2019, the Department of Health and Human Services made public a 440-page document known as the Final Conscience Rule.¹ It isn’t quite final. And the state of California already is suing to stop it.² But the document represents the culmination of years of legal wrangling over whether physicians are allowed to have consciences or whether they must function as automatons providing any legally permitted care that a patient might demand. This comprehensive document provides a history of the issues, but was written in dense legalese, as if it expected to be answering challenges in court.

The short answer in the United States is that religious liberty continues to triumph over editorials in the New England Journal of Medicine. Consciences are allowed. The Final Conscience Rule begins with “The United States has a long history of providing protections in health care for individuals and entities on the basis of religious beliefs or moral convictions.” That history includes the Religious Freedom and Restoration Act of 1993.³ RFRA was introduced into the Senate by Sen. Ted Kennedy (D-Mass.), a bastion of liberal health care policies, and passed by a 97-3 vote. It was introduced into the House by then-Rep. Chuck Schumer (D-N.Y.) and passed by a unanimous voice vote. RFRA is not the invention of Republican fundamentalists.

For my colleagues in Canada, the Ontario Court of Appeals (ONCA, the highest provincial court) decided on May 15, 2019, that the opposite situation is the law in Canada. A recent Ontario law concerning medical assistance in dying (also known as physician-assisted suicide) requires Ontario physicians to either provide the assistance when requested or to make an effective referral, defined as “a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency.” Some Canadian physicians objected to this requirement as a violation of their consciences and their Hippocratic Oaths. They lost. The ONCA decision is 74 readable, double-spaced pages and spells out the ethics and legal principles. In summary, the ONCA said the policies on requiring an effective referral “strike a reasonable balance between patients’ interests and physicians’ Charter-protected religious freedom. In short, they are reasonable limits prescribed by law that are demonstrably justified in a free and democratic society.”⁴

The California physician-assisted dying law, known as the End of Life Option Act, which became effective in 2016, has policies which are very different from the Ontario policies. The California law has clear protections for the consciences of physicians. The law empowers them to avoid being compelled or coerced into cooperating with these deaths. “Participation in activities authorized pursuant to this part shall be voluntary. … A person or entity that elects, for reasons of conscience, morality, or ethics, not to engage in activities authorized pursuant to this part is not required to take any action in support of an individual’s decision under this part.”⁵ If it seems strange that California would strongly protect conscience with its own statute but challenge the new federal regulations, welcome to tribal politics.

The point is that the role of physicians in abortion, physician aid in dying, and other controversial practices is not going to be decided by philosophical discussions about the ideal scope and purpose of medicine. Compromises are involved that reflect the values of society. Canada is more anticlerical than the United States, and Ontario chose a different path. French culture is even more extreme. Recently, mayors in two towns in France told their elementary schools to stop offering alternative entrées on days when pork was served for hot lunches. Secular schools were not to provide accommodation for students (Muslim and Jewish) who religiously objected to pork. Since the French Revolution, the emphasis is on assimilation and laïcité (France’s principle of secularism in public affairs). The cathedral Notre-Dame de Paris – recently damaged by fire – is owned by the state, not the Catholic Church. The United States has a different history and culture. It has supported religious liberty and reasonable accommodations. That is the loving thing to do. But as a reminder, the Peace of Westphalia in 1648, which ended European religious wars between Protestants and Catholics, was not a result of enlightened thinking and agapeic love. The fighting parties looked in the abyss of mutual annihilation and opted for coexistence instead.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

References

1. Department of Health and Human Services, “HHS Announces Final Conscience Rule Protecting Health Care Entities and Individuals,” May 2, 2019.

2. “California sues Trump administration over ‘conscience rule’ that could limit abortions,” Los Angeles Times, May 21, 2019.

3. Wikipedia, “Religious Freedom Restoration Act of 1993”

4. Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393.

5. California Assembly Bill No. 15, End of Life Option Act.

The article was updated on June 21, 2019.