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April 18th, 2021

Podcast 276: Pay attention to the structural barriers that contribute to clinical inequity — Karol Watson

(6 votes, average: 3.67 out of 5)

In this, our second conversation on race and clinical equity, Dr. Karol Watson of UCLA offers her observations on what she’s observed as a cardiologist trying to deal with treatment plans for patients who’ve lost their health insurance or have had to go to a plan that doesn’t cover what’s needed.

She reminds us that tagging people as “non-compliant” would often be better expressed as “unable to afford.”

Let me know what you think, please, at jelia@nejm.org

Running time: 10 minutes

April 11th, 2021

Podcast 275: Race and Clinical Equity — a Conversation with Dr. Kimberly Manning

(13 votes, average: 3.54 out of 5)

We’ve conducted a set of four interviews with physicians on the topic of race and clinical equity.

The conversations center not so much on their published research, but on the roles that these physicians take in their organizations and, in addition, the stories they tell about their own experiences.

Our first is with Dr. Kimberly Manning, who’s a professor of medicine at Emory.

Let us know what you think. Write to me at jelia@nejm.org.

Running time: 20 minutes

January 18th, 2021

Podcast 274: Preliminary Thoughts on the 2021 ASCO Gastrointestinal Cancer Conference

(26 votes, average: 2.35 out of 5)

Apologies for the long silence. We have been off doing other things — one of which has been figuring out how to cover conferences. Last month, after much preparation, we covered the American Society of Hematology (ASH) annual conference; our second foray consists of brief coverage of the American Society of Clinical Oncology (ASCO) gastrointestinal cancer symposium.

We present a brief, pre-conference chat in this edition. It was conducted just before the ASCO conference began, to get a sense of our guides’ expectations. Those guides — David Ilson, Ghassan Abou=Alfa, and Axel Grothey — are interviewed here and will be interviewed again at the end of the conference. The are expert, respectively, in cancers of the esophagus; stomach, liver, and pancreas; and the colon and rectum.

In forthcoming interviews, I will share several of the interviews done with hematologists for ASH. I hope you will find them as fascinating as I have.

Running time: 19 minutes

August 29th, 2020

Podcast 273: The journals and the pandemic — NEJM

(8 votes, average: 4.00 out of 5)

Eric Rubin is editor-in-chief of the New England Journal of Medicine.

I asked him how COVID-19 has affected that journal, which has been around since the War of 1812 and seen its share of pandemics.

Listen in — it’s the first in a planned series of interviews with the editors of the principal clinical journals.

Running time: 19 minutes

NEJM’s Covid-19 resources page

TRANSCRIPT

Joe Elia: Welcome to Clinical Conversations. I’m your host, Joe Elia.

Dr. Eric Rubin, a specialist in infectious diseases, took over the reins of the New England Journal of Medicine as its editor-in-chief about a year ago. He had just enough time to settle in before — you know — the biggest pandemic in a century arrived.

He’s kindly agreed to take part in what’s planned as a conversational survey of the editors of the principal medical journals about their takes on COVID-19. These chats won’t focus so much on the clinical science of the pandemic as much as its broader effects.

In addition to editing the Journal, Dr. Rubin is an associate physician at Brigham and Women’s Hospital and a professor in the Department of Immunology and Infectious Diseases at the Harvard T.H. Chan School of Public Health.

Welcome to Clinical Conversations, Dr. Rubin.

Eric Rubin:: Thanks, Joe.

Joe Elia: These have been strange times for medical journals, haven’t they?

Eric Rubin::They sure have. I don’t have much of a basis for comparison, but as far as I can tell, this is pretty unusual.

Joe Elia: Yeah. I mean how is the journal doing? You’re all working in isolation? You’re not up in the top of the Countway Library on Shattuck Street, these days, are you?

Eric Rubin:: Yeah. That’s right. We’re all shut down, although I must say it’s worked out pretty well to have people working from home. I suspect that, like a lot of businesses, we’re going to find that we don’t have all that many people in the office when we finally do get back.

Joe Elia: I remember from years ago the kind of bustling newsroom feeling at the journal offices, and you would have these conversations in the corridor, like oh, you know, “This thing just came in, you should take a look at it,” but you really can’t do that over Zoom so readily, can you?

Eric Rubin:: Yeah, I think that’s right. It’s not as if we haven’t lost something.

Joe Elia: Yeah.

Eric Rubin:: It’s so much easier for people to walk in and out of each other’s offices with questions or ideas or “Here’s just something cool,” so we miss that, and I’m hoping that we recapture that, but on the other hand, there’s a lot of just get the work done stuff that people can do very efficiently at home, much more efficiently.

Joe Elia: Yeah. Yeah. When I was there, people would say, well, you know, “How often does the journal come out?” And I would say “Every damned week.” It’s relentless.

Eric Rubin:: That’s right. It’s kind of relentless.

Joe Elia: Yes. So, have you been inundated with research reports?

Eric Rubin: We have. I will say it’s gotten a lot better, but at its peak, we were getting more than 200 manuscripts a day, 7 days a week, for a while, just on COVID-19, on top of really a pretty normal volume otherwise.

Joe Elia: Yeah, my gosh. So, electronics have helped you distribute that workload, I guess, but that’s a lot of reviewers to find.

Eric Rubin: It is. We have to filter, before we send out for review, pretty severely, and finding reviewers is also problematic because the reviewers that we want to use are also quite busy. They’re the people taking care of the patients with COVID or setting the policy.

So, people, I think the reviewers have been very generous, but it did mean that we took a rather severe cut when things came in, thinking, you know, “This just is not likely to make it, and the authors are better off going somewhere else, where they can get a real serious look.”

Joe Elia: Yeah. You know journals have often been called universities without walls, but now, a lot of information, especially biomedical information, is being swapped around on social media, but they are kind of universities without constraints. What’s your feeling about this — this kind of swapping of information that’s going on?

Eric Rubin: You know I have mixed feelings. On one hand, I like the fact that information is being democratized and anyone can see it and comment on it, and that’s certainly true of COVID-19, where we and many of our fellow journals are making everything available immediately for free access right away, immediately, so that everyone can read the same things that the experts are reading.

When I look at social media, though, there’s a real mix. There’s really learned commentary, and there’s real misinformation, and it can be hard, I think, for people to sort out what’s real from what’s not.

Joe Elia: Can journals then offer a kind of healthy skepticism and peer review? Is that what they can bring to the table?

Eric Rubin: I think for sure. There’s no question that we make a lot of changes in every manuscript that comes to us. We work together with the authors, but the final product generally looks a lot different from what was submitted and different from the preprint that’s been posted.

And some of those changes — a lot of them — are cosmetic. A lot of them are messaging questions, making them more understandable or more accessible or being very clear about what the investigators did, but a lot of them are substantial.

For example, it’s not unusual to change the conclusions of a manuscript and sometimes change them to the opposite of what the authors had said originally, and that’s a pretty big change, and it is.

So, I think we’re still playing a role in communications that is very important, and we do that, certainly, with the very big help of our peer reviewers.

Joe Elia: So, those changes, Eric, are made with the — of course — with the consent of the authors. I mean they’re not just made and published. I just want our listeners to understand that.

Eric Rubin: Absolutely. This is a collaboration with our authors.

Joe Elia: Yeah.

Eric Rubin: When we accept a paper, we’re a little bit different from many scientific journals. We generally decide, after peer review, immediately, we’re going to take this or we’re not. It’s very unusual for us to send it back and say, “You know, if you did some more experiments, we’d reconsider.” Generally, we write a letter that says “We’d like to publish this, but as long as we can work with you to make the changes that we think are necessary,” and those are — can be — very extensive.

Joe Elia: This pandemic is an event that’s affecting culture, in some ways in the same way that the AIDS epidemic did, and by which I mean that, you know, human interactions and politics as much as creating an urge to solve the problem biomedically, but would you agree that the pandemic has become unusually politicized?

Eric Rubin: It is. It’s very strange but absolutely. I think the parallel that you point to with HIV is a good one, and back when HIV was in its heyday and treatments were not so good…not that HIV’s gone away. I don’t mean to suggest that.

Joe Elia: Right.

Eric Rubin: But back when there weren’t many therapies and there was a very strong advocacy movement, it was a very frustrating time, and that led — and people may not recall this — but that led to a lot of sort of crackpot theories that got propagated very widely in the community and were ascribed to by a lot of people, and that really undermined, I think, their confidence in the system.

Now, in the case of HIV, what brought confidence back was having effective therapies. It really was a technical fix. It wasn’t a political fix. Now, we’re in an even more difficult situation, I think, because our most effective means for controlling the virus are simple. They’re social engineering, in a way. They’re wearing masks and social distancing and all the standard sort of stuff, and yet we’re not really able to implement them, in the US at least, as widely as we should because of this politicization of the questions.

Joe Elia: You know Rudolf Virchow, back two centuries ago, said that medicine is a social science, and these simple, you know, measures that you mentioned are part of the social science — probably — that needs to be done.

Eric Rubin: Well, you know, and I think that goes back, again, back to HIV. I think it’s a really good point. In HIV, all we had originally were control measures, and those control measures meant people had to change their behavior in ways that they didn’t want to change, and it was very difficult. The uptake of that was difficult, very parallel to today, and what made the difference was actually not a social intervention but a technological fix, and I think, once again, we’ve come to rely on technology that we’re incredibly reliant, right now, on the idea that a vaccine will be successful.

Joe Elia: You know, speaking of HIV, when I was at the journal, a long time ago, at the Shattuck Street offices, we had a telephone call from Michael Gottlieb in Los Angeles in 1981, and I happened to be the senior person in the office at the time, I think Bud Relman was off on one of his trips, and he [Gottlieb] said, “Gee, I’ve got four cases of something, how soon can you publish an article?” and I said, “Well, you know, 3 to 5 months is what we’ve got.” So, I said “What is it?”

And he said, “Well, you know, it’s this kind of infectious thing that’s predominantly among gay men,” and I said “Do you think it’s a public health problem?” And he said, “I do,” and I said “Go to MMWR [Morbidity and Mortality Weekly Report (from the Centers for Disease Control)] and submit it there.” And he did.

And the next day, Bud Relman was back — the editor of the journal in those days — and he called Gottlieb and said, “Yeah, go to MMWR and we’ll publish the whole thing later.” And we did in, I think, December, like something like 6 or 8 months later, we published his article.

So, I mean, Randy Shilts and his book “And the Band Played On” says, “Oh, you know, Gottlieb went to the journal and the journal pooh-poohed it.” But it’s not true, but it makes it…

Eric Rubin: And the journal had the first report, I have to say, in a medical journal of HIV back then. Technology is better now so that we can publish things much more rapidly, and we can get them online instead of in print.

Joe Elia: Yeah.

Eric Rubin: Like we had to do back then but that it still requires people, and that is still the resource that’s most difficult for us. We put a lot of hours into every article, and we’re still putting in the same hours. They’re just compressed into a weekend.

Joe Elia: Yeah. Early in the pandemic, the journal published a letter about asymptomatic, or yes, presymptomatic transmission, for which it was…it got some criticism. Turns out that it was correct, that the letter was correct, but that.. You’re on the firing line, a lot, aren’t you, as the editor? You can be accused of saying, oh, you know, the journal is trying to be first, and it’s not always…that’s…

Eric Rubin: Yeah. I think that’s right, and I think we should be criticized when we make mistakes, and we should act to try to rectify those. In that case, we happened to be right, and we were vindicated by subsequent studies, but you know that was a case of politics as much as anything. That was a message that people didn’t want to hear and they were very resistant to at the time.

You know it’s no surprise that the biggest subsequent issues, in general, in medical journals have been about hydroxychloroquine, which has a very faithful following, and when anything gets published, we have a lot of people who object if it…and we would have people objecting on either side if the article suggested that it worked or it didn’t, and we’re also in the position, put in the position…we get a lot of people writing, saying “Why didn’t you do this?” We didn’t actually do the study, so it’s a little hard for us to…but they’ll criticize our characterization of the study as positive or negative, and I think we’re doing the best we can, and it’s very fair to second guess us. That’s part of the interchange, but it can get a little personal.

Joe Elia: So, when you think about your role, Dr. Rubin, do you see yourself as a teacher, a referee, a ringmaster? When you think about your audience, who is it?

Eric Rubin: Well, that’s a really good question. We like to think of our audience as clinicians, as people who are taking care of patients. The truth is that we publish a range of things, some of which are aimed at practicing clinicians and are very practical. They can be the videos in clinical medicine which show you how to intubate a patient or how to do any given procedure or the CPCs, the various clinical series we have where discussants develop a differential diagnosis and come up with management plans for patients. The research articles, we try to characterize, at least in summary, in ways that anyone, that any clinician could understand the message. Now, the truth is, we do have, and we have more and more of what I guess I’d call experimental medicine, which is something that’s not yet ready for primetime.

It can be phase I studies. It can be first-in-man studies, occasionally, of new drugs or new techniques, and I still think that’s important because a clinician can see what’s coming next, what do we have to look forward to? This may or may not be a breakthrough, but it could be, and we’d like to get those out to our audience.

Admittedly, some of what we publish is very technical and is aimed at a subspecialist or occasionally really a researcher community, but we’re trying to serve everybody to some extent. Our goal is to make a difference in how people are treated, and I think we try to think of the audience that matters for making that sort of impact.

Joe Elia: If you considered yourself a ringmaster, how do you get the lions and tigers to behave?

Eric Rubin: Well, so, I guess that requires a little description of the process we go through to make decisions on manuscripts. Essentially, all the editors sit in a room, at least until we shut down the office. Everyone shows up. There are 30 people in a room, and every manuscript that’s gone through peer review and has some chance of being accepted gets presented. Actually, it’s very old-fashioned. The editor who’s handling it Xeroxes all the figures, hands them around, and then presents the papers if it’s a journal club, and then there’s a very interesting discussion where the experts in the room or the people of opinions in the room, or of educated opinions in the room, will bring up any aspect of it, was the design correct, are the statistics correct?

We have several PhD professors of statistics sitting in the room. Was it ethical? Was there equipoise? Could you do this study? Almost any aspect of it gets discussed, and at the end, we make a decision. It is kind of a strange position to be in to be the final decision-maker because so many people in that room know more than I do, but it comes to a balancing act of what do we think people really need to know, and what’s going to move the needle? And I think that gets discussed all the time. In fact, one of the key questions that comes up repeatedly is, “If we publish this, is it going to help or hurt patients? Are people going to take this incorrectly and potentially do harm, or is this really going to make a difference?” And if it’s really going to make a difference, we’ll definitely publish it. So, it’s a fascinating process. You know it’s the world’s best journal club.

Joe Elia: Well, I want to thank you, so much, Dr. Rubin, for speaking with me today.

Eric Rubin: Thanks, Joe.

Joe Elia: That was our 273rd episode. We come to you from the NEJM group. Our executive producer is Kristin Kelly, and I’m Joe Elia. Thanks for listening.

August 7th, 2020

Podcast 272: And now for something completely different… almost

(8 votes, average: 5.00 out of 5)

Dr. Paul Sax writes the closest thing that the NEJM Group has to humor. He’s serious, of course, since his blog “HIV and ID Observations” concerns all things infectious . But he sprinkles in the odd cartoon or links to … dog videos, fer cryin’ out loud.

He scours the ID literature (and we must include the social-media literature in that category) for interesting stuff to write about, seems to have a knack for summarizing whole conferences in 750 words, and often manages to give his readers a reason to smile in these fretful times.

We decided to catch up with him and ask him about his inspirations and for his advice. He doesn’t disappoint.

Running time: 10 minutes

Paul Sax’s latest “HIV and ID Observations” blog: “Carbapenems and Pseudomonas, Lyme and Syphilis Testing, a Bonus Point for Doxycycline, and Some Other ID Stuff We’ve Been Talking About on Rounds”

TRANSCRIPT:

Joe Elia: This is Clinical Conversations. I’m your host, Joe Elia. The current pandemic is leaving its mark all over the place, and one obvious area is in medical research. Clinicians are often hearing about new findings on their car radios on the way home or on social media. The credibility of that information is key.

Our guest, this time, is Dr. Paul Sax. He’s a contributing editor on NEJM Journal Watch Infectious Diseases, Clinical Director of the HIV Program, and Division of Infectious Diseases at Brigham and Women’s Hospital, and also a Professor of Medicine at Harvard Medical School.

Globally, he’s probably best known for his lively blog, “HIV and ID Observations,” which he posts almost every week on the NEJM Journal Watch site.

Welcome, Paul.

Dr. Paul Sax: Thanks, Joe, for inviting me.

Joe Elia: I’ve been reading your most recent blogs, which I’ll remind listeners are all available at Blogs.jwatch.org. One of the most recent is titled “Reaching Out to Infectious Disease Doctors in COVID-19 Hotspots: You must be truly exhausted.”

I get the sense that you’re talking more to working clinicians than policy makers or professors like yourself. Whom do you imagine is reading your observations?

Dr. Paul Sax: Well, I actually meant it for the entire infectious disease community. Kind of, if you think back a million years ago, to March 2020, we were starting to hear about this terrible thing that was coming our way. We all knew it was coming, but we didn’t know exactly when it was going to happen, and then it happened at different times in different parts of the country. So, while we were preparing here in Boston, and New York City was getting slammed, other parts of the United States were preparing, too, but they didn’t get hit the way we did in the Northeast.

So, you know, I have colleagues in Alabama and Atlanta and Florida and Texas and Arizona, and you know, things were pretty quiet there. They did have occasional cases, and what happened was that, unlike here, where we really got hit hard (and we fortunately, at least for now, knock wood, things are very quiet, for them,) they had a period of relative quiet and then, a large number of cases. So, they’ve had to sustain this intense involvement with COVID-19 response right from the beginning. Very tough.

Joe Elia: Yeah. You’ve been at this for just over 12 years, with the stated purpose, and I’ll quote, “Commenting on interesting HIV, infectious diseases, and other medical and not-so-medical news.”

Is that still your purpose and what has the reaction been over the 12 years?

Dr. Paul Sax: Well, it’s been really gratifying — and gratifying in a way that I never could have imagined. You know, I’ve always kind of imagined myself someday becoming a writer. I’m a frustrated comedy writer. Never quite made it to Hollywood, but I went to medical school and I went into this fascinating field, and I thought, you know, “Why not write about infectious diseases?” And I’ll tell you, my inspiration for the format really were some of the great blogging in the early 2000s, mid-2000s, where writing just exploded on the internet and I thought, “Wow, all this great writing available for free. Let me try my hand at it,” and I’ve got to thank Matt O’Rourke at NEJM Journal Watch for giving me the opportunity to do it.

Joe Elia: Well, in the not-so-medical department, you’ve been known to sprinkle in cartoons and lately, dog videos: “Olive and Mabel,” two Labradors. I’ll just say it’s British genius comedy, but what’s that got to do with infectious diseases, Paul?

Dr. Paul Sax: Well, you know, there’s this strategy that every infectious disease doctor does when you’re talking to patients — is you ask them about their exposures, and one of the ways we ask about exposures is you ask about pets, and of course, I wouldn’t probably be so fixated on the dog videos if I didn’t have a dog myself, which I truly love, but there is this sort of funny aspect of infectious diseases where you ask someone about their pet, and then they look at you like, are you out of your mind.

I remember one unfortunate person who had a motorcycle accident and we got to the point where we were asking about pets and he then acknowledged that, yes, he did have a new parakeet, and then our infectious disease fellow I was working with said, “What’s your parakeet’s name?” And he told us: Fruit Loop. And I thought, that’s a very funny name. Of course, it had nothing to do with his motorcycle accident, or why we were seeing him, but there are times when it is highly relevant, and you know, there have been many times when we’ve seen people, and for example, they’ve acquired an infection from their pet and sadly, sometimes it is their beloved dog.

Joe Elia: Now you’ve confessed, already in this interview, to wanting to be a comedy writer, perhaps, and maybe even a standup comic when you were younger. What deflected you from that noble cause and was there a book or an experience, an infection or something that deflected you?

Dr. Paul Sax: So, yeah, well, probably the thing that deflected me the most, and I’m going to say this because I’ve acknowledged this on the site, is my father. My father, who is a physician himself, comes from a long line of physicians, and his attitude, essentially, was, if you’re okay in science, then you become a doctor. And he could not understand why his son, who was okay in science (that’s me) would consider doing something like comedy writing. He basically said, “Just go to medical school and then after that, if you still want to be a comedy writer, see if you can make it work.”

So, thanks, Dad. I mean I really love my field. I find infectious diseases fascinating from A to Z and beyond, and it’s always challenging, never more so than today, and you know, I get to do somethings that are sort of vaguely related to comedy writing.

I do want to also say, that in college I had some truly outstandingly talented friends who became professional comedy writers and frankly, I don’t have their chops.

Joe Elia: You can drop some names if you’d like.

Dr. Paul Sax: Yes, well, he was very kind t let me interview him about his own experience with a life-threatening disease, but one of my friends was Andy Borowitz. Andy Borowitz, of course, is a prolific writer writer now for the New Yorker mostly, political satire, but he’s just an extraordinarily talented person. And then another brush with greatness is Conan O’Brien. Conan O’Brien was a college friend of mine, and his father actually is an infectious disease specialist, so it all comes round, eventually.

Joe Elia: Now you serve as a kind of medical-cultural reporter on rather mysterious viral infections — HIV and COVID-19. Information on these diseases — and especially now, COVID-19 — comes at us unremittingly. Is it a hopeless task to try to keep up, or is it essential to try to keep up, and how do you, as a reporter, keep up for other clinicians?

Dr. Paul Sax: Well, I would say it’s essential to keep up and the way that we keep up is different from the way it used to be. You know, it used to be, you would get your journal mailed to you every week or every month, depending on the frequency, and you would pore over the table of contents, and read the abstracts, and the interesting papers. You’d read the methods, et cetera, and then the results.

Now, rapid fire medical information comes at you really quickly. I want to say that there are some good things about Twitter. Twitter actually is a great place to see medical information very quickly, but it’s not adjudicated, so the next step, after seeing that information, is to try to look at it critically

And I think a really good example of that is the dexamethasone treatment for COVID-19. The first I head of that was, of course, on Twitter. This group in Britain was promoting their results and it was very exciting that they had a press release showing a randomized clinical trial had improved survival with dexamethasone, and I kind of made the point after seeing their summary, that it should become standard of care for people with COVID-9 and met the criteria that used in their trial. And as a result, practice-changing. Their study was practice-changing and now it has been given the blessing of the New England Journal of Medicine, and I think we can say without much risk of bias that that is very high praise indeed, to be accepted as a paper in that journal.

Joe Elia: Yes. I think you’re right. And finally, as a reporter yourself, is there a question you wished I’d asked that I didn’t?

Dr. Paul Sax: Well, you know, one thing I do on my blog, is I try to write in my own voice, and that is something that I feel like medical journals could use a bit more of, and if I were to give some feedback to some of the medical journals, it would be this, it would be that there is a role for the human beings voice in the august pages of these journals. It doesn’t all have to be edited to fit the house style. So, that’s one pitch for that.

Joe Elia: Okay. That’s good advice, I’ll pass it on.

Dr. Paul Sax: Please do. To my good friend, Dr. Eric Rubin.

Joe Elia: Thank you, Dr. Sax, for talking with us today.

Dr. Paul Sax: Thanks, very much, Joe.

Joe Elia: That was our 272nd episode. All of which are available free at podcast.jwatch.org. Our executive producer is Kristin Kelley, and we come to you from the NEJM Group. I’m Joe Elia. Thank you for listening.

August 5th, 2020

Podcast 271: Checking back in with Florida — 4 months later

(5 votes, average: 4.20 out of 5)

Back in late March (people often tell me that, these days, 4 months ago might as well be 4 years ago) we talked with emergency physician Julian Flores, who was working out of Broward County. Covid-19 cases were modest in number but threatening to get worse, and indeed they did.

The county’s cases jumped 100-fold, from about 600 to over 50,000. Just south of Broward, Miami-Dade has double that caseload.

We revisit Dr. Flores (who was sheltering from the rains of a coastal near-hurricane in his car). He confesses bewilderment and counsels skepticism — especially of one’s biases — in evaluating this thing we’re facing.

 

Running time: 16 minutes

 

Other interviews on Covid-19 in this series:

  1. Dr. Anthony Fauci (NIAID, Bethesda, MD)
  2. Dr. Susan Sadoughi (Boston, MA)
  3. Dr. Matthew Young (suburban Delaware)
  4. Dr. Julian Flores (Broward County, FL)
  5. Dr. Kristi Koenig (San Diego, CA)
  6. Dr. Renee Salas (Boston, MA)
  7. Drs. Andre Sofair and William Chavey (New Haven, CT, and Ann Arbor, MI)
  8. Dr. Comilla Sasson (volunteering in New York City)
  9. Dr. John Jernigan (Centers for Disease Control, Atlanta, GA)
  10. Dr. Ivan Hung (Hong Kong)
  11. Dr. Steven Fishbane (metropolitan New York)
  12. Dr. Michael Gonzalez (Houston, TX)

TRANSCRIPT:

Joe Elia: 

Welcome to Clinical Conversations. I’m your host, Joe Elia, and I’m joined by co-host, Doctor Ali Raja, of the Mass. General Hospital, and Harvard Medical School.

Back in March, Ali and I interviewed an emergency medicine physician, from Broward County, Florida. Back then, Broward had just over 600 cases, and as of this afternoon, August 2nd, confirmed cases there stand at nearly 100-fold higher. It’s some 58,000, with some 750 dead.

So, we’re checking back in with Doctor Julian Flores, who is still working there, in Broward County, as an emergency medicine physician.

Welcome back, Julian.

Dr. Julian Flores:

Hi, guys. Thanks again, for having me.

Dr. Ali Raja:

Hi, again, Julian. Thank you for chatting with us today, especially on your day off. How are you doing? What are you seeing clinically there, right now?

Dr. Julian Flores:

So, I’m seeing a resurgence of cases, of COVID-related complications. Also, essentially, paired up with just volume of ER patients, in general, and you know, it is in the background of us, as a state, in Florida, pulling back the restrictions that, essentially we were, quote unquote, forced to put in the first place, after we were delayed, related to the rest of the country, in doing so, which makes it that much tougher to deal with.

Essentially, both situations, right? Because you know, you can only increase your staff, or your resources, or just sort of, your energy, so much, right, to meet those multiple needs. Hindsight’s 20/20, but it’s kind of hard to imagine the alternative, when we’re just so early, still, relatively, even if it’s been — what? since around January — that we’re dealing with this? It’s still relatively early for us to know what trend the virus is going take, as a virus in general, us as a society, the other things that are inevitably altered, as well, economics, the schooling system, familial structures, et cetera.

Joe Elia:

Back in March, I remember you telling us that although you were working Broward County — and I understand you’re also working in Miami, as well, now — you were living in Miami’s Financial District, and you told us that you saw many groups of people, together in the street, without masks. I’m guessing, and hoping, that things have changed, since then.

Dr. Julian Flores:

Yes. It’s essentially, it’s not the stark opposite of that. I’d say something at least in the middle of those two scenarios, right? Of no mask, versus everyone with masks. I will say that Miami-Dade County has implemented what I believe, a fee of sorts, or some sort of penalty, if you are seen in public, without a mask. We, at least, collectively, have seen that as an important measure, against, at least, the exposure to the virus, or you know, giving it to someone, and transmitting it.

Dr. Ali Raja:

That makes a lot of sense, and like the rest of the country, I think we’re seeing that shift. Let me take you back to March, again. When we spoke, you were using one N95 mask, per shift. So, what about now? What’s the availability of masks, of gowns, of other PPE, in your experience?

Dr. Julian Flores:

Well, because I feel like, or rather, I know that even as a country, in most states, we’ve seen sort of, I would say almost a bimodal peak, in that we saw a surge…speaking of ER volume, in general, we saw a peak of COVID-related cases. We then saw, generally speaking, a dip in just ER volume, in general, from what you can infer, most people just being scared to be at all associated with an environment that, in any shape or form, can expose you to a virus, just by you physically being there, to now, a resurgence of truly related, both primary complications, and secondary complications of COVID, with just volume, in general.

Thankfully, I feel like that sort of dip in volume, and in resource utilization has allowed us to, in a way, catch up, with PPE, at least, I can say, in my hospitals, and you know, speaking for other hospitals in the area, as well. So, I can say that the resources in the two shops I work for are thankfully there, but I can’t speak, you know, for every hospital in Florida.

Dr. Ali Raja:

That makes sense, and you just spoke about the hospitals. What about the hospitals, in total? How are ICU beds doing? Have they started bringing elective procedures back, or are they still holding out on them?

Dr. Julian Flores:

That’s also, from what I know, sort of, a hospital-by-hospital scenario. I know that as a state, that’s not a sort of, a uniform, now, limitation. My hospitals are allowing that to happen. Of course, there’s always, I can imagine, that back thought, in an interventionalist’s mind, that if it doesn’t need to happen now, and it doesn’t harm the patient, then maybe in the spirit of just limiting exposure in general, that it can be delayed, somewhat. At the very least, that’s being allowed to happen.

Joe Elia:

Do you have enough ICU beds? I mean, are…

Dr. Julian Flores:

Yeah. That’s also regional, when thinking about Florida. There are some ICUs that I know are at easily 90-something percent capacity.

Joe Elia:

Yeah. Okay.

Dr. Julian Flores:

And if not that, at the very least, we are holding more patients, in general. That’s something I feel like I can more easily generalize, to the state of Florida, that there are just more patients being held in the ER, secondarily, to just folks either in an ICU setting, or in what we call a PCU setting, taking a little bit more time to be discharged.

Joe Elia:

Okay. How are you keeping informed? There’s so much information, just bouncing off the walls about these things, and I don’t think that hydroxychloroquine was an issue, when we first talked. But I mean — and we don’t need to talk about that — but there are lots of advisories out there, and you had mentioned a private Facebook group, in our earlier chat. Are you still active in that, and finding it useful?

Dr. Julian Flores:

Definitely. I’m still a part of those, a couple of Facebook groups — private groups — I mentioned before, one of them being EM Docs, and the other one being the COVID-19 Physician Alliance. You know, there’s always going to be a lot of mixed messages, and comments that could be … in a way, you can say, they’re true. But there could also be another truth that’s mutually acceptable, right?, because as we all know, data can be presented — consciously, or subconsciously — how we want it to be presented, without altering numbers, or methods, as to how we acquired the data points, to begin with.

So, and of course, it’s hard to divorce the emotional sort of, drive, to be presenting that data, to begin with, right?, and to come up with a conclusion, whether you’re, you know, pro, or anti anything, really, in general, especially in regards to the pandemic, and how we’re handling it, and how the virus is going to be projected to continue affecting us.

Essentially, at least, what I do, is every time I look at, sort of, even a study that was well done, I try to think of if, in any way, the alternative could be true, right?, and if I’m already biasing myself pre-meditatedly, before I’m reading the study, because that’s going to color how I see it, going through. That’s going to color how I’m going to be spreading it to my colleagues, and to my friends, and family.

Again, we’re relatively pretty early into COVID-19. You know, and because of that, as much as you would like to, you can’t always make a study as diverse as possible, or as extrapolatable as possible, right? You can only do so much, when you’ve been in a pandemic for what?, eight months, or so, right? So, they may all come from a good heart, or a good, sort of, intention in mind, but I always try to read the opposite viewpoint, or a journal that would refute that.

So, you know, in many ways, in regards to things like hydroxychloroquine, or certain other related medications, sometimes the safer thing, I think, going into it, is to just have no opinion on it, because sometimes, we just don’t know, and we can’t apply every single patient, every single demographic, every single hospital to that end point, because I mean, for any study in general, for any medication, the number of days that you use it matters. If you use it at the beginning, during, or after, the height of, the peak of symptoms, et cetera.

So, it’s tricky, and I feel like we all, you know, reflexively want to have an answer, and we’re not going to convey it, always, that unambiguously, especially if we have an emotional drive to put that home.

Joe Elia:

Or a political drive, as well.

Dr. Ali Raja:

It could be either.

Joe Elia:

Yeah. Yeah.

Dr. Julian Flores:

And those are mutually not exclusive, either, right?

Joe Elia:

That’s true. That’s true. We want to believe what we want to believe, and so, I think we all face that, as human beings.

Have you been hearing from colleagues who haven’t faced a surge yet? There aren’t too many places in the country that aren’t, but have you heard from any, and do you have advice for them? We interviewed you in March, and now, here we are in August. And what was the big lesson that you’ve learned, over those months, if you had to give one?

Dr. Julian Flores:

Yeah. I would say to my colleagues, that haven’t been dealing with COVID-19 related symptoms, or complications, as much as the rest of us, to just keep your eyes peeled, because it’s hard to say that a specific ER, or a specific region, within Florida, or within any state, is going to be inherently immune to it, when we’re still allowing transportation within the state, across the states. And conversely, folks that have been dealing with only COVID-19 related, you know, pulmonary symptoms, or other organ system complications, not everything is COVID-19 related, either, right?

We’re still going to have our strokes that are just related to a vascular complication, independent of COVID, or heart attacks, or trauma-related complications. So, I think in either extreme, we just always have to, in these times, remember to just keep our eyes peeled.

Dr. Ali Raja:

That is a great way to look at things, and a good reminder for all of us. Let me ask you, Julian, we’ve been asking all the questions. So, do you have any questions that you wish that we had asked? Or, a point that you’d like to make, that we haven’t gotten the opportunity to do, yet. What’s on your mind, that we haven’t yet covered?

Dr. Julian Flores:

I have a lot of opinions, and ironically, on a lot of COVID-related topics, and the conclusion, in those opinions of mine, is that I have no opinion — if that makes any sense.

Joe Elia:

It does.

Dr. Julian Flores:

Or, no. I have no, sort of…I can’t say with legitimacy, or with, you know, pure confidence, that it’s one way or another, especially something like this virus, that again, is a specific strain of coronavirus. As we’re coming to know, it’s not only pulmonary-related complications. It sort of, evokes all your organ systems, and any of them could be altered short term, or long term, at any given time. We’re still, you know, trying to figure that out. And with the mindset of always trying to see what the opposite team is saying, it has sobered me quite a bit, when coming to terms with what I think I know, or what I want to know, and what I want to convey to the general public, all while trying to keep a word choice, a spirit of, per se, it doesn’t have to be the end of the world, and at the same, this is not something we’ve dealt with before, at any level that you want to talk about it.

At the medical level, at the societal level, political level. It’s just, it’s not, and I think we’d be lying to ourselves to say that it is, in either way.

And everything is relative. That’s a main point I would want to drive home, and we have to see what terms we’re talking with, what truth we’re believing, before we speak, and are we allowing room for that alternative explanation to be said? Because there’s a lot of common ground, that can be found, and sometimes, it can feel weak, or it can feel, sort of, in a way, insulting, especially to us physicians, or healthcare-related folks, that are the main, sort of, proponents to driving home knowledge, of any kind of sort, to sort of, quote unquote give in to the other side, and again, because these points touch on a lot of things besides just logic, right?

We cannot deny that sometimes, subconsciously, or consciously, there is a political side-motive. There is an inherently, sometimes, again an emotional cord that’s being strummed in some way or another. So, I would just like to advocate for us all, sort of, being honest with ourselves with what we’re reading, what we’re deciding to read, what we’re coming out of, you know, getting from these articles, from these posts, from the news channels. And are we leaving room for the alternative explanation? If so, are we deciding to paint one picture, or another, based on something else besides just the facts at hand of COVID-19.

Joe Elia:
Julian, we’re very grateful to you, for doing this with us, today, and we want to extend our best to you, and your colleagues, and especially, to your patients. Thank you.

Dr. Julian Flores:

Thank you so much, and you know, as I finished, I believe, the last podcast we enjoyed, and collaborated in, together, you know, keep the hope. Keep the positivity. I think that’s, at least, what drives me, to keep reading, to keep wanting to know more for myself, and my peace of mind, and for our patients.

Trying to leave, you know, pride aside, and collaborating with, and you know, coming to terms with what could be the alternative of what we thought of, to now, in this, and just in medicine in general, because again, they’re not mutually exclusive, right? Especially in this sort of, wave of the virus where, especially as ER doctors, where we can’t afford to just see one thing, or another. I mean, we’re rolling the dice with every patient, with every, you know, clinical presentation. So, collaboration is what’s gotten us even this far.

Dr. Ali Raja:

That’s a great way to end this, Julian, to remind us, all of us, who are seeing patients right now, in this unprecedented time, to keep an open mind, and to be willing to collaborate, even when we might have initial doubts. That’s how we’re going to really move the treatment of this disease forward. So, thank you for that really important reminder.

Joe Elia:

That was our 271st episode. All are available, free, at podcast.jwatch.org. We come to you through the NEJM group, and our executive producer is Kristin Kelley. I’m Joe Elia.

Dr. Julian Flores:

I’m Julian Flores.

Dr. Ali Raja:

And I’m Ali Raja. Thanks for listening.

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