The Last Word

by Shanna Combs, MD, TCMS Publications Committee

This article was originally published in the May/June issue of the Tarrant County Physician. You can read find the full magazine here.

by Shanna Combs, MD, TCMS Publications Committee

I did not get into medical school.

I failed my oral board exams.

I lost my job.

It all sounds like the trailer to an incredibly sad movie.  But the reality of the situation is I am a board-certified obstetrician gynecologist who has the best job ever.  So how did I get here?

“Everything will be okay in the end.  If it’s not okay, it’s not the end.”

These are the words I discovered many years ago when a friend was going through a hard time, and it is still a phrase we shoot back and forth when times are tough and not going the way we planned.  This is the same friend that picked me up after receiving my rejection letter the first time I applied to medical school. I was not allowed to wallow at home alone—a night of dancing was in order.

Once the dust settled on the acute shock of “not getting in,” I had to decide if this is truly what I wanted to do.  I had been a ballet dancer for almost my whole life and was making my income as a dancer, teacher, and rehearsal coach, as well as working at the community college in the physics lab.  Such is the lifestyle of an artist and their multitude of jobs.

Upon not getting into medical school, I initially thought about working in education with the goal of teaching ballet.  Ultimately though, the call to Medicine was too strong, so I re-took my MCAT, took a biochemistry course, and set my path toward reapplication the next year.  I cast a broader net and, in the end, I obtained the privilege of placing “MD” after my name.

Fast forward a few years.  I completed my residency in obstetrics and gynecology, passed my written board exam, and began my career as an attending physician.  I found my way back into teaching as an assistant professor for medical students and residents.  (Guess that career in education was always going to be there.)  During this time, I collected my cases and prepared for the next step in board certification—the oral board exam.

Since you read the opening lines, you already know the outcome.  Let’s just say, I knew I had failed the minute I walked out of the exam.  “Everyone says that” is what I kept being told, but the following week I discovered the truth.  It was a difficult time for me.  I went through some frustration before I got to acceptance, and there were definitely times where I was not the best person I could be.  In the end, I dusted myself off again, pulled up my big girl pants, and began the process for taking the exam again the next year.  After multiple reviews of my case list, many practice exams/pimping/torture sessions, I walked in for my second try at the oral board exam.

I left the exam with a vastly different feeling.  I knew I had passed.  The following week, while driving back from Colorado with my parents, I got the good news that FACOG could also go behind my name.  My mom made me pull over, and somewhere on the side of the road in rural New Mexico we got out of the car to dance and celebrate my success.  

Fast forward a few more years, and we were hit with the global pandemic: COVID-19. The world as we knew it was changed forever.  Little did I know that my personal world was soon to change as well.  A few months into the pandemic, I was notified that the clinic I worked for had terminated my contract without cause.  I lost my job.  How does a busy obstetrician gynecologist lose their job in the midst of a global health crisis?  I will never know—that is the problem with the phrase, “without cause.”

In life there will be successes and there will be failures.  We always talk about the successes but almost never talk about the failures. 

Once again, I found myself wondering what the next phase in my life would entail.  I remembered not getting into medical school and wondering if I even wanted to be a doctor anymore.  I had worked so hard to get to where I was, yet I was questioning it all over again.  Soon after finding out I had lost my job, a friend told me, “You know, you really have not been happy for the past year or two.  Maybe this is just what you needed.”  Harsh words to hear at first, but in the end, she was right.  So, once again I dusted myself off, put on my extra big girl pants, and looked for what I was going to do next.  

I have found true joy in working in the field of women’s health, but I always had a special interest in taking care of kids and adolescents.  Too often this population gets lost in the shuffle.  I am now happy to say I have found a new landing spot in pediatric and adolescent gynecology.  Young ladies go through many changes during their young lives and even more so during the transition of puberty.  I frequently say, “Puberty is hard,” and I am now able to provide the care and support these young ladies need.

In life there will be successes and there will be failures.  We always talk about the successes but almost never talk about the failures.  However, it is within these moments that you learn the most.  So, why not talk about your failures?  I have truly found the honesty of my inner self when I fail.  I never thought I would be where I am today a year ago, five years ago, or 17 years ago.  Yet, I kept rolling with the punches and taking the next step forward always remembering, 

“Everything will be okay in the end.  If it’s not okay, it’s not the end.”

The Last Word

by Hujefa Vora, MD – Publications Committee

This article was originally published in the March/April issue of the Tarrant County Physician. You can read find the full magazine here.

The last words I wrote in this journal were printed in January 2020, after a family trip to Disney World:

“I returned to work in this New Year, in this new decade, invigorated. My optimism stems from the smiles of my baby girl and her beautiful mother. It stems from an understanding that our imaginations power our spirit and our spirit powers our hearts. This year, 2020, will be an amazing year for all of us because I will will it to be so. The world is full of magic. We are so blessed to be physicians. I needed a particular princess to remind me of this. Search your feelings, you know it to be true. I hope your year is starting out as well as mine. I pray that all of us can find perspective and optimism somewhere in this world, so that despite the bureaucrats and the obstacles and the hazards along our journey, we can continue to serve our patients in this, the highest of all callings in the Galaxy.”

This was quite obviously written before a viral pandemic spread across the United States, infecting countless numbers of our families, friends, and loved ones, killing over 500,000 Americans. It was written before our world changed forever.

Overwhelmed. Exhausted. Fatigued. These are the emotions that have defined our existence on the front lines of the COVID-19 pandemic over the last year. We have watched helplessly as many of our patients and loved ones have slipped away. We have held the hands of patients who have passed away in respiratory isolation, their closest loved ones on phones and miles away, not allowed into the hospital. But I have seen Joy, when the infection overwhelms but the body and spirit fight on, conquering the virus and returning our patients to health. We have seen families reunited after long battles in the hospital ICU or at home in quarantine. We have seen Hope. We have known Love. I have seen the fantastic power of the human spirit. I have seen God’s love, and the power of prayer. There were moments when I felt that I could no longer fight for myself or anyone else, when the exhaustion would creep into my bones, and leave me battered, bruised, and almost beaten. But we are physicians. And we work with amazing, powerful nurses, medical assistants, medical techs, therapists, and hospital administrators—a formidable health care team. So I saw unexpected acts of bravery, acts of selflessness, moments that were etched into my soul forever. I saw us fight an unknown adversary. I have been privy to courage and honor, as we wrapped our patients in an armor of hope. I have seen hands that are raw from washing and sanitizing and wringing but showed no signs of relenting or retreat or defeat.

And in early January of 2021, at the hospital where I have seen and experienced all of this, there was a moment where my hope was recovered, where I became recharged and ready to step back onto the battleground. I saw the proverbial light at the end of the tunnel, the sun peeking over the horizon at the end of a cold dark night. The promise of a new day. The vaccine.

“Overwhelmed.  Exhausted.  Fatigued.  These are the emotions that have defined our existence on the front lines of the COVID-19 pandemic over the last year.”  

As I received that second dose, I wondered how any of us survived this year. I wept tears of joy, thinking that I finally knew in that moment that we would make it through this war. The tears burned with the memory of all those we have lost. It didn’t need to get this bad. Why did we have to lose so many? And how many more will we lose? The answer depends now on our resolve. We must resolve to vaccinate as many of our patients as we can as soon as possible. As a medical community, we should assist our public health departments, hospitals, clinics, and our federal, state, and local governments to roll out these vaccines with great efficiency. The only way we will win this war now is by vaccinating the masses and following the public health guidelines to wash our hands, distance, and wear masks.

I returned to work in this New Year, 2021, reinvigorated. My optimism stems from the smiles of my colleagues, which have been renewed with hope that the tide is turning. My optimism stems from an understanding that our imaginations power our spirit and our spirit powers our hearts, and that science and ingenuity and heart will prevail with the advent of this vaccine. This year, 2021, will be an amazing year for all of us because I will will it to be so. The world is full of magic. We are so blessed to be physicians. Search your feelings, you know it to be true. I hope your year is starting out as well as mine. I pray that all of us can find perspective and optimism somewhere in this world, so that despite the ill effects of COVID-19 on all of our lives, and the obstacles and the hazards along our journey that was 2020, we can continue to serve our patients in this, the highest of all callings. I want to thank all of my colleagues and compatriots who have shared this year with me and my family. We have shown that together we are stronger, and we will overcome. My name is Hujefa Vora, and this is the Last Word.

The Evolution of Medical Education

by Monte Troutman, DO – Publications Committee

This piece was originally published in the January/February issue of the Tarrant County Physician. You can read find the full magazine here.

I can brag on myself as I have been involved with medical education for over 40 years now. Thirty-seven of those years were spent working as an assistant and then an associate professor of medicine at the Texas College of Osteopathic Medicine (TCOM) within the University of North Texas Health Science Center. I was the first full-time gastroenterologist there. I left private practice in Dayton, Ohio, where I was adjunct faculty at the Ohio University College of Osteopathic Medicine. I wanted to be more involved in medical education than that position offered. So why am I telling you all this? So you know that I have been around a long time and have seen a lot of changes, including monumental ones in medical education, from the classroom to clinical bedside clerkships. 

UNTHSC developed an Academy of Medical Educators where physicians, other health care providers, and basic scientists at TCOM have learned and discussed the theories and principles of medical education including Bloom’s educational approach and Miller’s framework for assessing clinical competence. 

After we learned the fundamentals, we now concentrate on other aspects of medical education. One of the of most significant changes that has transformed how we educate is that we no longer “lecture.” Indeed, it is now considered a four-letter word—lecturing is seen as passive learning.  Also gone are reading assignments from textbooks. Other forms of education now rule the roost. This includes online education and interactive forms of learning. 

So, what is so wrong with textbooks? About 10 years ago, I read a letter to the editor in the New England Journal of Medicine, where two second-year UCLA medical students calculated the total number of pages assigned by instructors for one semester. A staggering 10,000 pages were assigned and were fair game when testing occurred at the end of the semester. Too much? Yes!

A recent Google search stated the doubling of medical technology in 1950 was 50 years, in 1980 seven years, in 2010 three and a half years, and in 2019 one and a half years. Now in 2020 it is 73 days; not even three months. I recently told this to a fourth-year medical student on my service and as his eyes widened, he exclaimed, “That’s scary!” So, to revisit what is wrong with textbooks, here it is: The editors work with other experts to write a designated chapter, all work is edited and corrected, it is then published, printed, distributed, and purchased, etc., etc. This whole process takes years. So how many times has medical technology doubled in that time frame? Educators still refer to textbooks, but as references, not as primary education material.

A man walks into a bar in New Orleans and asks for a Corona and three hurricanes. The bartender hands him the bill—$20.20. Yes, the COVID-19 pandemic has changed things, possibly permanently. Virtual medical education is the current modus operandi. Zoom, WebEx, Skype, and Join.me, to name a few, are the classrooms today.  Right now, learning clinical skills is generally virtual. Inconceivable but true—not hands on but virtual patients. Not entirely new, just brought to the forefront due to the pandemic.     

Over the past several years, the lecture (that four-letter word again) hall has been sparsely filled unless attendance is mandatory, as some medical schools still do require, or if an in-person quiz is on the schedule. Before attendance began to drop, medical educators made the classroom an interactive session and the iClicker was used to respond to questions. However, with Power Point presentations now online before the lecture is given, and voice over with the Power Point, why go to the lecture hall? Pull up the Power Point whenever you want, play it at 1.5 to 1.8 speed, and listen to it twice. The thought is that the classroom is wasted time, and you avoid being called on in class. 

There is still in-person training. I teach in the second year, which includes small group sessions called Clinical Reasoning Modules (CRMs). In the CRMs, about eight to 10 students are presented with clinical cases by a moderator who leads the discussion on history, physical, labs, imaging, etc. The model used is a version of clinical reasoning called a “mind map,” and it stresses differentials and necessary testing and imaging. Grading is based on participation. As the “clinical expert,” I rotate to all the small groups and answer questions.  This is where I get to meet students I have never seen before. 

So, if there are no textbooks or lectures, what do the students do to prepare or to learn? Good question! Instead of scheduled lecture time, regular time is scheduled during their day to “study.” Faculty prepares Directed Student Activities (DSAs).  The DSAs include society guidelines, videos, online sites like Up To Date and more. Here textbooks are listed, usually as reference rather than test material. As you can imagine, the students are very resourceful and tell me about sites they find on their own that support their learning process.  The list I have been informed about and use to refine my DSAs are Baby Robbins, Pathoma, First Aide, Sketchy Medicine, Get Body Smart, Picnomics, and Hardin MD. As you can imagine, the time spent by faculty to screen all these sites is overwhelming. Since our curriculum is problem-based, symptoms or problems are the topics of our DSAs. Since I am a gastroenterologist, my topics are abnormal liver chemistries (not called LFTs anymore), nausea and vomiting, dysphagia, GI bleeding, constipation, diarrhea, and so forth.  Can you imagine the time needed to condense these topics into DSAs that are current and learnable using this format?

 I have been around a long time and seen a lot of changes, including monumental ones in medical education, from the classroom to clinical bedside clerkships. 

To worsen the situation, clinical clerkships have been adversely affected by the pandemic. Many institutions banned medical students from direct patient contact, and in some instances, from entry into hospitals or surgery centers. Virtual patients were used to teach clinical skills devoid of in-person contact or interviewing. When will they get to see patients in person and learn bedside and in-office clinical skills?  Who knows with the recent COVID-19 surge. Some have learned telehealth clinical care, which in some cases may be here to stay. Recent legal issues about student participation in clinical care have also started to cloud the problem. How will all this impact future clinical skills? 

So, all these issues in medical education will indeed have an impact on health care. Medical educators have their work cut out for them in the new learning environment compounded by a seemingly never-ending pandemic. Not only are medical students educated to pass boards and clinical competencies, but to become lifelong learners. They must learn without DSAs and with doubling of medical technology every several months. When do they learn cost restraints, physical exam, and other competencies? 

I know that this essay is called the Last Word, but this is hardly the last word on this topic. Hold on to your hats—this is a new world. Who knows what the new normal will be? As for me, the Last Word is that knowledge can be communicated, but not wisdom.

The Last Word

by Robert Bunata, MD – Publications Committee Interim Chair

This piece was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.


After our first year of college, my little group of high school friends had a summer reunion.  Ed was pursuing literature and publishing, Steve accounting, and Roger a business degree.  We had the following conversation after Roger said, “I have a great idea. You be the doctor and I’ll run the business.”

To that I replied, “Why would I do that?  I’ve watched my father and mother run their business just fine for years. I think I can do it myself with a little help and I’d have control like my dad.” 

“But with smart business practices you could make more money and I’d handle the stress of the paperwork.”

“Granted,” I said, “I might make more money, but that’s not what I want. I want freedom, control, and to do what I’ll be trained for, to take care of patients.  I want to make sure my business runs like I want. And, besides, I’d have to pay your salary as well as mine, meaning I’d have to take home less or charge the patients more.” At that time I failed to add: “Besides, Roger, if I approach my patients with a bill collector they would think I was only interested in making money and not in them.”  

Over the next decade or two, due to the mix of new health insurance companies, specialization, technical development, and lots of greed, medical costs got out of hand and the specter of Roger came back in the form of big business and managed care.  

About 25 years ago, as our autonomy was being eroded, I wrote an article for The Physician advocating that doctors stand up for their rights.  I went so far as to recommend we form a union even though it was illegal.  But I did not have a plan or even an idea of what to actually do.  Business and politics won and they set the agenda for the practice of medicine, and we followed like sheep to the slaughter—literally to the slaughter in the form of burn-out, depression, retirement, and suicide.  

“We should admit that we gave up control of our profession too easily, and let politicians and businesspeople define who we are.”

Two recent articles I read express the same exasperation. Richard Byyny, MD, and George E. Thibault, MD, have recently published a monograph entitled, “Burnout and resilience in our profession.”1 Since I am unable to paraphrase the article satisfactorily, I will quote the part I found most interesting, shortening where possible. 

Our current problems with burnout were anticipated by sociologists who posed that bureaucratic and professional forms of organizing work are fundamentally antagonistic. Medical schools do not yet prepare graduates as practitioners who can best resist the bureaucratic and market forces shaping health care and the care of the patient. 

Physicians experience conflict between what they …should do, and what they have been educated and socialized to do. They have been professionalized for acquiescence, docility, and orthodoxy. They are taught to be more like sheep than cats—ultra-obedient following the rules. They are not taught to be cats—independent activists – … advocating for medical values.

We have prepared physicians to follow the rules; however, whose rules? The rules generated by … (our own) … profession?  Or the rules generated by the organization with different values and objectives?

As a result, physicians see professionalism more about conformity. This creates a conflict in the current health care system and organizations. Physicians seem to be perverting core principles of the profession to a just-follow-the-rules … practice of medical professionalism. We are essentially responsible for the problems we now encounter, especially when the care of the patient is often not the focus.

We need cats who will resist conformity in service of extra-professional forces. The mission … (should be) about saving health care for patients and society and enabling (us) … to care for patients and not experience burnout.

That article was sitting in my mind when I came across another— “After the storm”—by Siddhartha Mukherjee, MD, subtitled, “The pandemic has revealed dire flaws in American medicine. Can we fix them?”2 Mukherjee is an oncologist who won a Pulitzer Prize for his book, The Emperor of All Maladies: A Biography of Cancer. He says he wrote this article to use this tragedy to improve American medicine.  First he discusses the points of failures in the organization and implementation of the medical distribution system, and the tendency to buy the cheapest foreign products (masks, gowns, pharmaceuticals), shunning our local providers. He especially criticizes the underfunding of medical research and public health.   

Then he reaches the most interesting part of the article, an anecdotal story about how he contacted doctors in different parts of the country on Twitter and Facebook to share ideas on treating COVID-19 patients.  In their informal transmissions they shared minute by minute discussions like the cause and treatment of thrombi, or how to best position patients to breathe. That improvised social media exchange drew his attention to the fact our balky, billion-dollar electronic medical record (EMR) system doesn’t provide a medical, but rather a financial database.   

These articles tell us that we need some housekeeping, some specific and some general changes.  By “we” I must emphasize that means every doctor, not just a few with an interest in politics.  This involves not just every doctor’s practice or earnings, but our whole life.  If we don’t work together and improve this, burnout will spread like COVID-19.   

There are many things that need improvement (to my mind too, especially the underfunding of medical research), but I’d like to look at two specific changes to consider.  

The first specific change is improving our EMR system to make it more medically useful. Mukherjee’s anecdote tells our story.  If we compare our EMR to the system in Taiwan— which may or may not be fair given such factors as their size and homogeneity—their electronic health records system made a swift targeted response to COVID-19 possible.3 Although the system was not designed to stop a pandemic, it was nimble enough to be reoriented toward one. The government merged the health card database with information from immigration and customs to send physicians alerts about patients at higher risk for having COVID-19 based on their travel records.  

While the U.S. has come a long way with its use of electronic records, thanks in part to the financial incentives built into the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the sharing of data—so called interoperability between different electronic health record vendors—has lagged. It’s expensive, but shoring up the U.S.’s digital health infrastructure will help improve routine care while empowering us to better respond to future infectious disease outbreaks.4,5,6 

Next specific change, the topic of EOBs, is one of my pet peeves.  Whenever I get an EOB for services I’ve received, the doctor’s charge is high compared to the payment received.  This is especially obvious dealing with Medicare EOBs with approved payments from Medicare being about a third of what the doctor charges.  When physicians see an EOB, we think how we’re being underpaid, but many patients have told me they think it shows the doctor is overcharging.  When I see this, I think this is exactly what “Roger” would have done, and it paints a bad image of doctors.  It makes us look like we’re only interested in making money and not in them.

As you can imagine, the list of improvements we could make can go on forever. But the point is we have to work together to improve the practice of medicine and the lives of doctors. 

Now for the general changes to consider. They are more vague and difficult to enumerate.  In my opinion, we should admit that we gave up control of our profession too easily, and let politicians and businesspeople define who we are. For instance, we should stop ridiculous requirements like having our payments reduced if a patient doesn’t take his medicine. We should take back what is rightfully ours—control of our profession, our practices, and our lives.  A big part of burnout is the feeling of not being in control; the best way to feel like we’re in control is to actually be in control. While I don’t have a detailed plan to do this, identifying the objective is a start. This should be a prime issue on the agenda of the AMA, AOA, TMA, TOMA, and of every doctor.  

Another general change concerns professionalism.  We all know what professionalism means on an individual level: put the patient’s interests ahead of our self-interests. We have all done that at one time or another—missed a Thanksgiving dinner or a child’s soccer game.  But what does professionalism look like on a national level?  What does it mean to put the nation’s patients’ interests ahead of our collective own?  While I have a few ideas I would rather not reveal them now. I am asking each of you to consider the question and write a letter to the editor or send an email with your observations and ideas. You can email us at editor@tcms.org, or mail us at 555 Hemphill St, Fort Worth, 76104.

References
1. http://alphaomegaalpha.org/medprof2015.html

2. After the storm. New Yorker, May 4, 2020

3. https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation

4. https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation

The Last Word: Post-Truth

by Robert Bunata, MD – Publications Committee Interim Chair

I don’t consider myself to be a superstitious person, but when certain omens appear, I am not one to tempt fate.  That’s what happened recently when I read a series of publications, two books and a book review, all pointing in the same direction, and suddenly became credulous, convinced mysterious forces were at work. 

All three publications, in one way or another, discussed present-day marketing of pharmaceuticals. The first was Salman Rushdie’s Quichotte, a story based on Cervantes’ Don Quixote.  The protagonist is a salesman for his cousin’s budding drug manufacturing company.  They are both immigrants from India.  The cousin got a “great idea” for selling his new powerful fentanyl nasal spray from reading a business card handed to him by an urchin in Mumbai that said on its front side, “Do you have a problem with alcoholism?”  Turning the card over explained, “We can help. Call this number for liquor home delivery.” It’s all very clever, but deceptive, and, eventually, as we know from our own opioid epidemic, disastrous.

The second was a book review by David J. Elpern, MD. Out of curiosity I read the book itself, Ghost-Managed Medicine, Big Pharma’s Invisible Hands, by Sergio Sismondo.  (Ghost-Managed Medicine is available for free online at http://www.matteringpress.org/books/ghostmanagedmedicine). The book tells of the author’s extensive investigation into several drug producing and drug marketing companies’ roles in influencing doctors’ diagnosing and prescribing.  It describes how drug companies “ghost-manage the production of medical research, shepherd the key opinion leaders who disseminate the research as both authors and speakers and orchestrate the delivery of CME courses. In so doing, they position themselves to provide the information physicians rely on to make rational decisions about patient care.”  These medical authors are prominent and often academic physicians with credentials in a given field who get paid or are otherwise compensated for adding their names as authors to papers even though they may not even read them, let alone participate in the research.  They are also paid to speak at cost-free CME courses.  Sismondo emphasized that such articles don’t mispresent information or lie.  The questionable part was the “ghost” association of the author(s) with the articles to enhance credibility.  (As a side note, I was especially disappointed to see members of our profession so susceptible to selling their reputations.) While Rushdie’s book was somewhat funny while being scary, this one was just plain scary because of the blatant perversions it reports.  

The third was a review by Jack Coulehan, MD, of the book, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, by Anne Harrington, PhD.  Harrington, according to Coulehan, describes medical science’s effort to find chemical and/or physical causes for mental illnesses and their treatments.  The creepy part of this book was a sentence discussing the efficacy of antidepressants which reads, “In an analysis of all clinical trials performed with six widely prescribed antidepressants—not just published studies, but those withheld from publication by pharmaceutical companies—it was found that the drug(s) outperformed placebo in only 47 percent of the studies.” (My italics.)  Why did they withhold those studies from publication?  One can only imagine.  Another topic the article reported was the underutilization of lithium after the expensive antiepileptic drug, Depakote, was approved for bipolar disorder in 1995, despite the fact that lithium is at least as effective and much less expensive.  Hence this is another book that records covert marketing efforts to guide medical choices.    

These three pieces pretty much speak for themselves.  I couldn’t help remembering when I was growing up and in medical school, I readily accepted that what I was told was true, that the therapies I was taught were the most appropriate, not the most profitable, and that lecturers taught without concern for compensation.  Our country was still basking in the victory of WWII and we had a feeling of unity.  We had confidence in our leaders and government institutions.  We overlooked the little lies of Eisenhower and Kennedy as oddities, not defects in character.  Then the discords of race relations and Vietnam took away our trust.  We were forced learn a certain level of “civic skepticism” appropriate to a democratic society.  

“It seems the level of skepticism is over our heads.”

Now, it seems the level of skepticism is over our heads.  Instead of everybody being entitled to their own “opinions but not their own facts” (to paraphrase Senator Daniel Patrick Moynihan), we have a continuous stream of “alternative facts,” ghost-writing, fake news, and post-truth.  The main news source for many, social media, is rife with dishonest, emotion-provoking opinions posing and accepted as true.  Some sites are outright dishonest; Wikipedia has a list of more than eighty fake-news websites, and even the most popular websites vary in their insistence on truth.  For instance, in October 2019, Facebook, reportedly very influential in the 2016 election, made the controversial decision to exempt most political ads from fact-checking, while Twitter decided to ban political ads completely.  While lying, cheating, and post-truth have also been around as long as man, they seem to be more wide-spread, becoming accepted as normal and main-stream.  This may seem, at first glance, to be nothing to be concerned about, but it’s a blurring of reality, and eventually, as we know from the experience of Germany in the 1930s, can turn out to be disastrous.

Back to how this relates to medicine.  In my literary meanderings I found this excerpt from a 1988 presidential address Robert J. Lefkowitz, MD, quoted by Douglas L. Mann, MD (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115645/): in the article “Fake News, Alternative Facts, and Things That Just Are Not True. Can Science Survive the Post-Truth Era?” 

The importance of honesty in research is not over the issue of truth vs. blatant falsehood that our integrity is most likely to be compromised. It is rather in the realm of a whole series of more subtle corruptions that integrity may be tested…. whereas lying involves falsity, bullshit involves fakery: it is essentially phony rather than false…In a sense, these bullshitters are even greater enemies of the truth than liars. At least the liar is guided by the truth, for to lie he must first define what he takes to be the truth. Not so the bullshitter. He pays no attention at all to the truth. Overindulgence in bullshit thus ultimately tends to corrupt the most fundamental aspect of the scientific process, the founding of conclusions on accurate and appropriate data.

So, what was the message I took away from these musings caused by my mysterious forces?  I am reminded to be alert and not take anything for granted or at face value. I should check my sources, verify “facts,” ask questions, and be careful not to spread half-truths, post-truths, or lies myself. Most importantly, I must keep my own “confirmation bias” in check.  We must all protect the reputation and integrity of our noble profession and not let the morals of business people, insurance executives, drug companies, and (especially) politicians, define the standards we live and practice by.