This article was originally published in the March/April issue of the Tarrant County Physician. You can read find the full magazine here.
Medical school has one primary goal: passing on humanity’s medical knowledge to a new generation. There are a few challenges to accomplishing this goal. First is a static problem, i.e., the sheer magnitude of information. Second is a dynamic problem, i.e., the rate of change of this information. Humankind’s medical knowledge is growing and being refined at an incredible rate. These forces are constantly at play in medical school, and they only become more obvious the deeper one’s understanding of a topic becomes. Learning more means absorbing all of the idiosyncrasies and all of the exceptions as well as confronting the burden of complexity. This is a problem that our species has been dealing with forever. Just take the ancient story of Adam and Eve; life was simple until they ate the apple and had to deal with the consequences of knowledge.
“Drinking from a fire hydrant” is the analogy often used to describe the intensity of learning in medical school. This is what medical students volunteer for beginning in year one, and it will continue until we retire. The best and only solution is old-fashioned hard work and careful thinking. This is the reality that you have to accept if you choose to be a doctor. Unfortunately, this same reality of drinking from a fire hydrant now applies to our whole society that is woefully unprepared for the flood of medical knowledge and information.
Our society’s fire hydrant does not come in the form of a pathology textbook, but in the form of the Internet and social media. Everyone is bombarded with health content, and the mishandling or misinterpretation of this information has many potential problems. These can range from wasted patient resources to creating false expectations—they can even lead to physical harm. As doctors we become familiar with information overload and have the opportunity to develop strategies to handle it. We learn to be skeptical, research thoroughly, test our assumptions, and rely on experts. It is sometimes easy to assume the whole world has some of these strategies too, but this is obviously not the case. I don’t even need to give a specific example, just browse Twitter or Facebook for a few minutes and I am certain one will present itself. Ideally, everyone would have instant access to a healthcare worker to help them navigate the things they see online. This is currently impossible, so many patients will have to sort through the overload of truth and misinformation on their own. In light of this problem, I am reminded of a famous quote by a pillar of our profession:
“One of the first duties of the physician is to educate the masses”1
–Sir William Osler.
I believe that we can benefit society by educating our patients about strategies to sort through medical information they find online. Strategies like having some skepticism toward this information, researching it through reputable sources, and trying to disprove something they see on social media before they believe it. Strategies that we have had the opportunity to develop through our medical education.
I am like most second-year medical students and I am probably too eager to share what I have learned with those around me. What has been surprising to me is that most of the health questions my friends and family ask or the incorrect assertions I hear are different from what I expected. For every time I get to explain how someone’s medication works, there are five times of disputing something someone saw on social media. I understand that not everyone has the benefit of medical school, but I fear that the massive amount of online health information has the potential to cause harm if people do not have basic strategies to handle it.
In closing, I will admit that the quote I used was not complete. The full quote says that “One of the first duties of the physician is to educate the masses not to take medicines.” I completely misrepresented the quote because it demonstrates how the simplest strategies can be used to check the validity of something you read. One Google search is all it takes to gather evidence that I was not being completely truthful with Dr. Osler’s claim. That being said, if Osler were alive today, I believe he would agree with the sentiment that “One of the first duties of the physician is to educate the masses not to believe everything they see online.”
1Osler, William, Robert Bennett Bean, and William B. Bean, Sir William Osler Aphorisms: from His Bedside Teachings and Writings, (New York: Schuman. 1950).
Interested in learning more about the risks and rewards of using telemedicine in your office? This month, TMLT will be hosting an ethics CME on the topic. The seminars will take place on April 20 and 28 and will be streamed live.
You can register here. If you have any questions, call 800-580-8658, ext. 5050.
All Oscar wanted to do on that cold, wet January day was to push his car out of the mud. Instead, he ended up in the ED.
“I felt a pop in both knees and my whole weight came down on my left knee,” he says. “I had to wait for the pain to pass and when I got up, I was not able to walk the same . . . I went to the hospital and was told to look for an orthopedic surgeon.”
There was a problem, though. The 64-year-old grandfather of seven did not have medical insurance and could not afford to see a specialist. To make matters worse, the injuries he sustained forced Oscar to quit his job as a dishwasher for a local restaurant.
“The pain from walking was unbearable,” he says. “My wife had to look for a job to financially support both of us.”
The couple, who had been married for 45 years, were determined to find a solution. Oscar went to Mercy Clinic to see one of their volunteer physicians, when he was referred to Project Access Tarrant County.
This wasn’t Oscar’s introduction to PATC—he was seen in 2017 by PATC volunteer Dr. Frank “Trey” Moore, urology, for treatment of kidney stones. While his urology care ended out being non-surgical, his physician realized that Oscar’s knee injuries would likely need more extensive treatment.
He was quickly connected to PATC volunteer Dr. Bret Beavers, orthopedic surgery, of the Orthopedic and Sports Medicine Institute. Dr. Beavers determined that Oscar needed surgery to treat cartilage and tendon tears in both of his knee, so PATC coordinated his care at Park Hill Surgery Center.
“Dr. Beavers is very friendly, and he explained everything to me,” Oscar says. “My treatment at Park Hill Surgery Center was amazing. I did not feel any pain from beginning to end.”
After two surgeries, one in each knee, Oscar’s condition quickly improved. One of the best outcomes was that he was finally able to rest peacefully, something he had missed while suffering from his injuries.
“Sleeping used to be very difficult for me because I would toss and turn all night due to the pain,” Oscar says. “Thank you, Dr. Beavers, for helping me. May God bless you so you can continue helping people like me.”
A lot of misinformation is circulating about the COVID-19 vaccine. If you want to know fact from fiction, take a look at TMA’s fact sheet on the COVID-19 vaccine, where top vaccine rumors are addressed with clear answers from the physicians who are taking care of our communities.
This piece was originally published in the March/April issue of the Tarrant County Physician. You can read find the full magazine here.
We can all learn in many ways from the intellect of Greece and Rome. This principle applies to infectious events which took place in those societies in the long distant past and were well documented by ancient writers in their descriptions of early epidemics.
In these difficult COVID-19 times we still rely on these empiric approaches obtained from past management of epidemics in times of war and peace. We have also learned how to complement this management with careful scientific research and study to develop more specific treatments and successful vaccination programs. Additionally, we have learned that it is important to have consistent, well-coordinated public education.
The Athenian Plague
This plague occurred in the setting of the Peloponnesian War, a long war caused by conflicts between the states of Athens and Sparta and their allies.1,2,3 Democracy originated in Athens in 500 B.C. It was brought about through the assembly of the 500, a group chosen to make important decisions regarding essential affairs of the city.
Athens, expanding into Attica and controlling the surrounding Ionian Islands, established the Athenian (also called Delian) League and built a naval empire. It became wealthy by exporting olive oil and wine and trading silver from nearby mines. It thrived under Pericles, a leader who built the Parthenon and encouraged culture and creativity in the city.
Sparta, by contrast, was a land-locked military state comprised of rigorously trained soldiers. It was ruled by kings that controlled underclass servants. They also expanded into neighboring city-states. Athens and Sparta became rivals that clashed due to their different styles of government and policy.1,2,3
The Spartans also built their own defensive alliance, the Peloponnesian League, which antagonized the Athenian League.
Athens protected its neighboring states from Spartan attacks and built walls between Athens and Piraeus (also spelled Peiraieus). To prevent further clashes Athens and Sparta signed a peace agreement, but the Spartans and their allies disliked the democratic and expansive Athenian approach and felt it needed to exercise greater restraint. Therefore, in 431 B.C., Spartan troops and allies made several incursions through Attica into Athens. This started a long series of battles with inconclusive results that were fought for 26 years in different sites either by land or sea. This ruined the Greek economy, adversely affected the lives of many families, and changed the course of Greek history.
This so-called Peloponnesian War has been described at length by the brilliant general and historian Thucydides and is still studied by contemporary researchers.1,2,3 The final downfall and cultural deterioration of Athens was caused by the combination of damage to its fleet after a failed invasion of Sicily and by the enormous loss of life caused by the Athenian plague.
This epidemic started in the second year of the Peloponnesian War, after the Spartan invasion and siege of Athens in 430 B.C. As reported by Thucydides, this disease appeared suddenly, with high fever, red eyes, sore throat and tongue, hoarseness and cough, vomiting bile, severe diarrhea, restlessness, purplish cutaneous pustules and ulcers, and also lesions over fingers and toes, sometimes with gangrene. Recent review articles suggest that the most likely epidemiological diagnosis was smallpox, with typhus being less probable.5 It did not appear to be bubonic plague.
Thucydides described the overcrowding in the walled city of Athens where he proposed the important concept of contagion of disease. He defined it as the transmission of illness from a sick person to a healthy individual. He was then influenced by the ideas of Hippocrates, who claimed that the secretions of a sick individual would contaminate the air during an epidemic.6
This proposal anteceded by thousands of years Pasteur’s and Koch’s observations on germ transmission. Thucydides also noted that death could occur on the seventh or eighth day of disease but observed that those who recovered might acquire partial immunity and did not die from a second round of disease.
Waves of infection affecting the local population led to the death of one-third of Athens’ inhabitants. So many of the dead remained unburied that at times the corpses piled up on the street. Thucydides blamed this on lack of humanitarian response of the survivors. He himself, who got the disease and recovered, suggested avoiding overcrowding and exposure to the sick; however, Pericles, who was leading Athens at the time of the infection, suggested the transfer of rural refugees to the walled city. This increased the risk of their contagion. He also became a victim of the illness, from which he did not survive.
Euripides, who also lived at the time of the war in 415 B.C., described in an allegorical drama, “The Trojan Women,” a prophecy for a tragedy that predicted the disaster that would befall Athens after the failed Sicilian campaign when Athens lost her entire fleet, and a large number of young sailors became enslaved. This was a message on bad war planning in a Greek drama written in the fifth century B.C.7
As Rome conquered Greek territories, the Roman Empire in turn was deeply influenced by Greek culture, which became integrated into buildings and sculptures. The Roman Empire was also influenced by their religious beliefs and images. Hellenistic centers created in Alexandria and in cities of Asia Minor were later absorbed and integrated into Rome.
The first recorded epidemic in Roman times was called the “Antonine plague.” It appeared in A.D. 165 to 180, and waves of disease followed between 211 and 266. To Galen, the observant Greek physician, the victims presented with fever, chills, sore throat, bloody diarrhea turning black, and a pustular rash on the ninth day consistent with smallpox. The acute phase of the disease lasted two weeks. It affected large numbers of Roman residents, with high mortality due to the density of population and excess of waste and sewage.4 It killed Marcus Aurelius Antoninus and Lucius Verus, the two reigning emperors.8 It is believed that the Roman soldiers brought the organism from Egypt and the Middle East into Rome.
In those times, early Christians were persecuted for refusing to honor the Roman gods. However, they endeared themselves to the sick for providing them with some form of care.
The Roman Empire later became stretched financially by excessive warfare, rapid emperor turnover, and increased civil wars. Rome was eventually sacked by invading Visigoths in 410, and the last western emperor was deposed in 476 A.D.
The Eastern branch of the Roman Empire was then established with Constantinople as the capital of what was to become the Byzantine Empire. A different type of plague appeared in 541 A.D. during the Emperor Justinian’s rule in Constantinople. Justinian (527- 565 A.D.) is known for military campaigns, civil law reforms (he wrote Codex Justinianeus), and for creating important buildings (Hagia Sophia in 562 A.D.).
It has been claimed that this plague caused the loss of up to one-third of the total Mediterranean population. It may have presented in recurrent intermittent waves that, lasted up to 200 years. It has also been suggested that it led to the waning of the Roman Empire and the advent of the Middle Ages.11
The historian Procopius (500 – 565 A.D.) described the appearance of this plague in Pelusium, Egypt, on the Eastern Nile, and its spread to Alexandria and later to Constantinople, Asia Minor, and the Middle East.
Procopius observed subjects with fever. They had “large painful swellings” in groins, armpits, and neck followed by delirium, black blisters, and vomiting, which frequently led to death. Occasionally, he noted, “The lumps start draining pus, the fever subsides, and the person sometimes may even recover.” There were similar reports from other observers at that time, like John of Ephesus.8
We know now that rats carrying fleas were brought in by ships supplying grain from Africa to Constantinople. Bubonic plague’s causative organism, Yersinia pestis, has been isolated and its DNA sequenced.10 This was obtained from tombs in sixth century Bavaria. It was found to represent a distinct genetic lineage originating from a different rodent reservoir for this pandemic than the one occurring in medieval Europe.
A recent detailed research paper by a multidisciplinary group questions the Justinian plague as being such a watershed event in history.9 After examining a series of independent fields of study such as papyri, inscriptions, and coins as well as pollen and burial sites, the authors conclude there is little evidence that the Justinian plague was a major driver of demographic change in the sixth century Mediterranean area. These findings indicate this plague was therefore very different from the devastating second pandemic that presented later in the Middle Ages.
We have learned that two ancient pandemics, the Athenian plague in early Greece and the Antonine plague in early Rome, appeared in cities with overcrowded populations. Their disease presentation at the time indicated exposure to a highly infectious, rapidly spreading agent that caused an acute, devastating disease of high mortality. Both epidemics had similar clinical presentation, in which fever and mucosal and pustular skin lesions predominated. We know now that they most likely represented smallpox, and this disease became airborne from mucosal lesions but could also spread by contact of skin ulcerations. It affected people of all social classes, including leaders and emperors. Such a contagious disease would have made patient care very risky and difficult. No wonder the corpses piled up on the streets of Athens!
Smallpox ravaged the entire world. It reached the Americas, including the U.S. and Mexico during colonial times. It decimated the Aztecs when the Spanish conquistadors arrived in Tenochtitlan, as the Aztecs had no previous exposure to this virus.
After Jenner published his spectacular results with vaccination in 1798, smallpox immunization was eventually adopted all over the world and the disease was completely eradicated by 1980.
Prevention of social gatherings was applied during the severe 1918 flu pandemic with measures such as closures of schools, shops, and restaurants, mandated social distancing, and home quarantining when needed. In cities in which these multiple recommendations were implemented earlier and kept in place, transmission of disease and mortality were reduced. This beneficial result demonstrates that avoidance of contact between individuals can be helpful in controlling transmission of highly contagious disease, which is why this approach is being used for the management of the COVID-19 virus.
1RMorkot-HistAtlas Ancient Greece- Penguin 1stEd 1996
2D Kagan – The Peloponnesian War – Viking 2003
3VHanson-A War Like No Other- RandomHouse2006
4ErinyHanna-Cities,Disease,Trade, Epidemics in Roman Empire Vanderbilt-Uni 2015
5RLittman-The plague of Athens. Epidemiol and Paleopathology. Mt.SinaiJMed 76:456
6HippocraticWritings:The natureof man Penguinclassic1983
7Euripides TheTrojan women Signet classic 1998
8GKohn; Encyclopedia of Plague and PestilenceWordsworth1995
9LMordechai-The Justinian Plague An Inconsequential Pandemic? PNAS 116-5125546
10D Wagner – Yersinia Pestis and the Plague – Genomic Analysis Lancet 14 April 2014
11Bassareo – Learning from the past in Covid-19 Era – Post Grad Med J 114:633
1Souza, Philip De, The Peloponnesian War, 431-404 BC., (Oxford: Osprey, 2002).