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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.    

Medical School in a Pandemic

By Shanna Combs, MD

These are interesting times here in North Texas.  I just spent the day completing an eight-hour curricular meeting for our Phase 2 Longitudinal Integrated Clerkship, all through online video conferencing.  These are the current social distancing times of COVID-19.  

Our students have also adjusted to this new reality, by having all their learning converted to online video conferencing.  This includes their small groups, where they work through clinical cases, develop learning objectives, then come back together to teach their fellow students what they have learned.  Their clinical skills sessions are also online where our students can work with their physician educator as well as standardized patients to hone their craft.  While not an ideal platform for teaching hands-on clinical skills, the students are getting introduced to the ever-increasing telehealth that has become more common during this pandemic and will likely be more common after the pandemic comes to an end.  Our students have also been able to engage with patient panels online, where the patients engage with the class in a conversation on their disease processes that are connected to the curricular content the students are learning.  

Unfortunately, during this time our students have also had to step away from their clinical duties, which currently includes working with a family medicine or internal medicine physicians for a half day every other week.  While the students are not able to participate in direct patient care at this time, they have not been deterred.  They now want to find other ways they can contribute to the local community during this pandemic.  They are working on a project to do readings of children’s books for children to access online during this time of sheltering in place and distance learning for all students.   Our students are also working to support and participate in blood drives as well as working on setting up a PPE drive to obtain the necessary PPE for our local clinics and hospitals who are in need.  They truly understand the meaning of being Empathetic Scholars™.

The students are also taking this time to work with their mentors (virtually, of course) for their Scholarly Pursuit and Theses project.  This is a four-year long research program where students work one-on-one with a local mentor to develop, perform, and ultimately present their own scholarly work.  Lastly, our Prep for Practice course is taking the current situation of the COVID-19 pandemic to highlight the many themes in their course including Ethics, Health Care Delivery, Health Care Policy and Advocacy, Informatics, Patient safety and CQI, Population Health, Physician as Educator, Psychological and Behavior Science, as well as Team-Based Care.  So many of these important topics can be highlighted through the lens of the COVID-19 pandemic.

While the pandemic carries on, we at the TCU and UNTHSC School of Medicine continue our work for our students, but ultimately for their future patients.  The COVID-19 pandemic will hopefully pass sooner than later, yet our students will continue in their education and be even more prepared for the next crisis in healthcare.  

The Promise of the Telemedicine: A Look into the Future

Reprinted from the July 1995 issue of the Tarrant County Physician.
by Jay Haynes, MD, MSc

The Promise of Telemedicine: A Look into the Future was originally published in Tarrant County Physician in July of 1995. The author, Dr. Jay Haynes, reflects on the changes that have taken place in telemedicine in the past 25 years:

During the managed care days and Clinton Administration of the 1990s, before the Internet, we had visions of using technology and telemedicine to improve access to care and the dreams to use it to better serve the underserved. A quarter of a century later, the massive use of telemedicine has now abruptly become a stark reality that is likely to transform the future delivery of healthcare. The recent spike in utilization and acceleration of telemedicine and virtual care during the COVID-19 pandemic crisis is unprecedented. Its adoption by Texas Department of Insurance and CMS has led to approved reimbursement, loosened bureaucratic regulations, and broadened telemedicine and telehealth access across the nation. 

In a recent poll by TMA, 74 percent of physicians in Texas began using telemedicine for the first time only after March 1, 2020. It is predicted that healthcare systems and physicians will continue to accelerate their capabilities and learn to adapt to evolving partnerships, technology, and communication to deliver care to their patients.

As we reflect on the past, we knew telemedicine was coming, we just couldn’t predict the exact “tipping point”  in time when the technology would be embraced. Who could have guessed that it would be a catastrophic public health crisis caused by a horribly infectious viral contagion that riddled our world and its healthcare systems in early 2020 driving us to use technology in order to connect with our patients and practice remotely and safely? 

Our handheld smart phone apps, platforms, and technology today are so much better than we would have predicted, and relatively, much less expensive than in 1995. The overhead cost of the modern-day virtual office visit and data storage is minimal compared to then. 

The objectives, potential applications, and challenges that are identified in the original article have stayed relevant. The value perception of the healthcare consumer continues to be driven by enhanced quality, convenience, and service utilizing evolving technology, adaptive systems, and innovative healthcare payment models. One point remains especially valid—the true promise of telemedicine is still to serve the underserved. 

And here is the original article from 1995:

In the last 100 years, our own social evolution has been driven by the quest for knowledge through enhanced communication. A century ago, great physicians and assistants would unite together in the disciplined arena of the operative amphitheater to observe and discuss the management of challenging cases. We are now able to reunite in the much broader “virtual electronic amphitheater” of telemedicine.

We have a responsibility as citizens, businesspeople, and leaders of healthcare to find innovative means of creating equity of access to healthcare, cost-containment, and uniform quality. The ultimate challenge of the future in healthcare will be to accomplish these social demands by uniting networks of healthcare providers and their facilities using tools such as interactive telemedicine systems.

The Frontier Ahead

“Telemedicine” is derived from the Greek “·tele,” meaning at a distance, and from the Latin “medri,” meaning healing. In 1971, K.T. Bird, the first pioneer to develop a complete prototype system in Boston, viewed telemedicine simply as “the practice of medicine without the usual physician-patient confrontation … via interactive audio-visual communications system.” He later reassured the medical profession that “telemedicine does not replace or regulate the physician; rather, it offers a new way to practice medicine.”

Current telemedicine systems utilize an interactive audiovisual system integrated with biomedical telemetry that allows a physician at a base station, specialty medical complex, or teaching hospital to consult with another practitioner, examine and treat their patient at multiple remote satellite locations, such as rural hospitals, ambulatory health centers, correctional institutions, facilities caring for the elderly, the home, ambulances, community hospital emergency departments, or international facilities.

Within the next 20 years every household in America will have access to a face-to-face consultation with a healthcare professional through interactive television. Diagnosis and management for many ailments and education about prevention will likely be rendered in the home by means of telemedicine. Patients will have one-on-one linkage to the best medical experts in the world. Psychologists and social workers may even be available for mediating family disputes.

Dr. Leland Kaiser has said, “The hospital of the future is the hospital without walls.” Every major competitor in the healthcare market of 2015 will be electronically, audio-visually linked to their patients’ community and home.  Quality, convenience, and service will drive the value perception of the healthcare consumer of the next century.

Telemedicine is the ultimate and timely management solution to our nation’s problems of rural healthcare access, over-utilization of medical services, loss of economical productivity due to illness, cost-containment, and quality assurance. With well-designed networks, a harmonious and cooperative relationship among healthcare providers and consumers will ensue.

The New Healthcare Gridiron

The era of traditional institutional healthcare is in its final stages. The paradigm of hospital and physician centered care has transformed into patient and community driven care. Wide and local area networks of seamless information transfer are replacing the past architectural designs of brick and mortar. The leaders of medicine who can best orchestrate the information change for the betterment of our society will surpass the expectations of the healthcare market of the next century.

The current environment of abrupt change in the healthcare industry presents an extraordinary opportunity for biomedical technology leaders to create economic abundance and job opportunities. Research and development, manufacturing, distribution, and servicing of interactive telemedicine systems and communication networks worldwide will serve the moral obligation of improved access, enhanced quality of care, and appreciably decreased relative costs of our current healthcare system.

Healthcare services are becoming more energy efficient, available, and accessible to even the most remotely isolated patients.  Medlife Corporation’s pilot project in an independent Rural Health Clinic in Groveton, Texas, employs a skilled physician assistant who successfully uses still-image telemedicine over regular telephone lines to consult with a physician in a tertiary health center 45 miles away. The telemedicine system acts as an adjuvant assistant, “High Tech with High Touch,” bringing more quality and efficiency to the patients and enhanced confidence and competence to the on-site provider. It has great ease of use and requires a minimal number of participants to facilitate its regular operation.

The Leap of Faith

Physician pioneers will acknowledge that telemedicine will broaden their scope of practice and range of services.  Patients perceive quality in terms of the value and effectiveness of service on site. Netting providers within an integrated framework with the common tool of telemedical communication will enhance the following applications:

  1. Initial urgent evaluation of patients, triage decisions, and pre-transfer arrangements;
  1. Medical and surgical follow-up and medication checks;
  1. Supervision and consultation for
    primary care encounters in sites where a physician is not available;
  1. Routine consultations and second opinions based on history, physical findings, and available test data;
  1. Transmission of diagnostic images;
  1. Extended diagnostic work ups or short-term management of
    self-limited conditions;
  1. Management of chronic diseases and conditions requiring a specialist not available locally;
  1. Transmission of medical data; and
  1. Public health, preventative medicine, and patient education.

Healthcare executive leadership’s decision to invest in a telemedicine system should be consistent with their institution’s mission and strategic goals, while satisfying the needs and concerns of its users. Potential objectives include:

  1. To perpetuate a proactive leadership role in continuous quality healthcare improvement;
  1. To enhance care and access to remote locations while preserving local autonomy;
  1. To link rural professionals with their urban colleagues;
  1. To decrease the burden and
    isolation of rural professionals;
  1. To serve the public, decrease costs, and save time;
  1. To support the infrastructure of a medical management information network;
  1. To redevelop trust of rural patients in local healthcare providers and the system at large;
  1. To decrease unnecessary
    transfers and overutilization;
  1. To deliver Continued Medical Education and reduce travel costs; and
  1. To access the global healthcare marketplace.

World League

America has the highest quality healthcare in the world, but it has also been the costliest and has neglected those who had the misfortune of indigence.  To be a universal competitor, we must implement a healthcare system that has excellent outcomes, constantly improves efficiency and quality, enhances access to the underserved, and reduces costs and time, ultimately increasing the satisfaction of the patients we serve.

Information of new developments and domestic and worldwide therapies are shared through telemedicine. Additionally, continued medical education is attained and tested through interstate or intercontinental didactic training. An incredible opportunity exists for health providers to be readily available and ON CALL to intercontinental business travelers who may become ill in foreign and third world countries. Telemedicine units placed in both domestic and foreign airports, as well as health institutions, would provide a value-added service which businesses and travelers would gladly purchase.

Hurdles to the Finish Line

Much of the waste in our current traditional healthcare system is in its fragmentation of specialization with overutilization and repetition of diagnostic testing. In addition, the “wind shield” time lost by provider traveling from hospital to clinic to hospital is unproductive. We must maintain continuity of care without subjecting the patient or provider to inefficient activities of travel, waiting, and redundant examinations. Telemedicine eliminates the loss of valuable time, measurable in dollars and expertise, as well as pain and prolonged suffering.

The prevailing concerns of telemedicine skeptics remain centered on issues regarding licensure, reimbursement and policy regulations, liability and confidentiality, system design, costs, and complexity of use. In our current system, a physician utilizing telemedicine to provide consultative services to patients in other states must hold a license in that state.  The FTC also has the issue of whether this would be deemed interstate commerce. New laws and definitions must be introduced that would allow unrestricted interstate trade for telemedicine.  A more practical solution would be to determine that the patient is “electronically transferred” to the physician’s state of licensure.

The Healthcare Financing Administration is analyzing outcome studies as it plans its strategy to pay for services. There is still great hesitancy on the part of many providers to enter the practice of telemedicine until the reimbursement and service valuation issue is resolved. Currently, HCFA is moving forward with a cross-cutting evaluation of telemedicine based on a series of three-year projects using waivers to reimburse for telemedicine consultations.

Political and congressional action is required to lighten regulations so that we may create vigorous telemedicine network systems with greater accessibility and freedom of choice.  This year’s fiscal budget cuts included much of the federal funding for telemedicine research and development. Access issues may be resolved if American citizens and private industry unite with a strong voice in support of telemedicine and its benefits.

Malpractice liability is always a prevailing question of potential users. To date there have been no malpractice claims regarding telemedicine. Practically speaking, the visual enhancement of current telephone communications should improve information exchange and decrease liability. However, one can be sure that as medical centers with “deep pockets” become networked with remote sites, an “Agency” relationship becomes established and our legal brethren will pay close attention to the potential for wealth transfer in the event of an unexpected bad outcome. Theoretically, their argument would rest on the perception of an “incomplete” exam. The telemedicine systems of the future will incorporate clinical practice guidelines and ensure adherence to community standards of care.

We have not established the standard of care for telemedicine. Most medical-legal concerns may be alleviated by utilizing mediation agreements and detailed informed consent. Utilizing telemedicine as a management and triage tool should be encouraged, especially if the visual/audio links do not provide adequate information transfer or resolution qualify to meet “diagnostic” standards of interpretation. We must make reasonable efforts to ensure confidentiality in telemedicine consults. To avoid electronic intrusion and exposure, encrypting algorithms will provide security. Although not foolproof, measures such as these are better than the open access systems that currently prevails.

The vast majority of both patients and physicians who have experienced telemedicine find it to be strikingly effective and useful. Now, with the second generation of telemedicine proponents in the newly organized American Telemedicine Association, the reality of telemedicine has truly come of age.

However, as in the last generation, resistance to change by those who have benefited greatly from the status quo remains the major hurdle to overcome.

Acknowledging the obvious improvements of quality and access as we integrate into managed care markets of the next century, we must evaluate the history of telemedical cases and consultations and place cost into the equation before we fully accept the effectiveness of telemedicine. The expense and production demands of interactive, full motion, video conferencing currently cost a staggering $65,000 per site unit, with operating costs ranging from $2,000 to $5,000 per month.

However, similar outcomes may be attained with less expensive, desktop still-image telemedicine systems. On analysis by selected generalist physicians, over 85 percent of all telemedicine consultations since 1990 did not require “full motion” for an adequate consultation. In fact, much less expensive, interactive digital “still-image” desktop telemedicine systems accomplish similar end results with maintenance costs equal to regular telephones.

Telemedicine systems must meet the needs of the user. It should be as easy to operate as a telephone. For some specialists, full-motion video conferencing may indeed be a necessary added value. For the majority of others such as family practitioners, physician extenders in remote clinics, home healthcare nurses, ophthalmologists, dentists, orthopedists, and dermatologists, the added expense of compressed full motion seems impractical.

Public (political) perception and need in this time of budget cutting dictates a search for the most efficient quality means to an end. Indeed, more controlled studies and research will be necessary. The current reasonable cost of entry into the high resolution, still-image technology with its ease of use and minimal operating costs may outweigh any potential shortcomings as compared to the more elaborate systems.

The true promise of telemedicine is to serve the underserved.  Telemedicine may facilitate quality healthcare to those who are home­bound or remotely isolated. It also presents a golden opportunity to stimulate the economy while serving society’s needy.


Jay Haynes MD, MSc, is a Family Physician  in Tarrant County  and  has been a member of the TCMS since 1987 and a past President of the Tarrant County Academy of Medicine. He serves as Senior Medical Director for Innovation and Integration for Acclaim Physician Group at JPS Health Network and also  Associate Professor of Family Medicine at TCU and UNTHSC School of Medicine in Fort Worth.

Sources

Preston, M.D., Jane. “The Telemedicine Handbook” 1/A TA Newsletter.

Negroponte, Ph.D., Nicholas. Being Digital.

Sanders, M.D., Jay. ‘’Telemedicine, Challenges to Implementation” Congressional Subcommittee on Investigations and Oversight Committee on Science, Space and Technology on May 2, 1994 

Tangalos, M.D., Eric. “Hearing on Telemedicine: An Information Highway to Save Lives.” Congressional Subcommittee on lnvestigations and Oversight Committee on Science, Space and Technology on May 2, 1994

The Crisis of Our Time

The President’s Paragraph from the May/June 2020 issue of the Tarrant County Physician.

by Tilden L. Childs III, MD, TCMS President

At the beginning of this year, I was asked by several people what my goals were for the Tarrant County Medical Society during my presidency. What projects was I planning to work on? At the time, I half-jokingly responded that I did not really have anything particular in mind (although I did), but that I was sure something would come along.  Well, as we all know now, something big and important and scary came along: COVID-19, the disease caused by the novel coronavirus now known as SARS-COV-2. The disease has caused an unprecedented disruption in the world. This was succinctly documented by The Economist magazine with a cover illustration of the world labeled with a “Closed” sign. As this is a rapidly evolving medical crisis with drastic implications for all walks of life and for our future, anything specific that I share with you at the time of writing this article may likely be out of date at the time of publication. However, here are some of my thoughts today.

First of all, I would like to share with you my unwavering appreciation and my awe at the overwhelming response of our medical communities at the local, county, state, and national levels. At the local and county levels, the TCMS leadership is working with and coordinating with the Tarrant County Public Health Department and with our city and county representatives and governmental agencies through our representation by Dr. Veer Vithalani, Acting Medical Director of Medstar EMS. The Tarrant Medical Operations Center (TMOC) has been activated by Dr. Vithalani to help coordinate the medical response in the community. We are also working with the local healthcare systems through our TCMS COVID-19 Task Force. TCMS is helping to facilitate the transfer of information to our local physicians as well as to provide a valuable resource to the media and the public. Additional TCMS projects include assembling a list of medical volunteers, helping to recruit and distribute personal protection equipment (PPE) obtained from community and public resources to local physicians’ offices, and monitoring the availability and progress of COVID-19 testing in Tarrant County. 

Also, TCMS is working with the Dallas County Medical Society to review the recommendations previously developed in the North Texas Mass Critical Care Guidelines document. Additionally, TCMS is working closely and integrally with the Texas Medical Association (TMA). The TMA has marshaled many resources together, has implemented a COVID-19 Task Force, and conducts daily telephone conference calls through the TMA Incident Command Center. The TMA daily morning telephone calls have approximately 100 participants. The TMA gives excellent daily updates of all of the activities being performed by the TMA as well as working closely with the members on the various concerns that have arisen during the course of the medical response to COVID-19.  The American Medical Association (AMA) has been working at the federal level as well. Of course, numerous resources are available online. TCMS provides information and updates on our blog. Additional information is available and is updated daily on the TMA and AMA websites. 

In times such as now, we all need courage- the courage to persevere, to serve, and to honor our commitment to our patients and our profession.

What I have observed at this point in time is that containment has given way to mitigation, which has given way to suppression, with increasingly severe restrictions on our daily life. This includes “shelter in place” restrictions and the closing of non-essential businesses. Of course, the goal of all of this is to “flatten the curve” of new infections over time so as to try to keep from overwhelming the healthcare system. Current estimates predict a decline in the curve sometime in mid-April to early May, and this appears to be occurring! 

Suppression strategies may work for a while, but what is the exit strategy? What will the “re-opening” of our society look like? Will it be relaxation of societal restrictions in conjunction with continued surveillance through extensive testing and contact tracing, new or improved treatments/medications, vaccinations, the eventual development of “herd immunity,” or what? The threat and severity of a “second wave” of infections following the relaxation of restrictions remains to be seen. Will COVID-19 become a seasonal disease? Will a vaccine be developed in time to prevent a recurrence of this crisis? This is doubtful, with current estimates of 1-5 years to develop a vaccine. Possibly the virus will become less virulent over time. Perhaps the “new normal” will represent a significant modification of our daily routines and practices as we learn to cope with this virus. Will tele-medicine/telehealth become entrenched in our practices? As always, time will tell.

For our healthcare system and particularly the members of the healthcare team, this has been and continues to be a time of great challenge and sacrifice. The uncertainty of the current situation and of the future is scary and anxiety provoking. We want clarity of the threat and the knowledge upon which we can trust and then to act accordingly to care for our patients and society as a whole. As this crisis has evolved, it has become painfully clear that expectations of a strong and swift federal government response were unfulfilled. However, I do believe this is not due to the lack of leadership by the medical profession at the highest levels of government. 

The ongoing critical lack of PPE and the slow ramp up of testing has been incredibly stressful and indeed threatening, if not outright harmful, to the health and welfare of our medical personnel on the front lines. This in turn threatens our ability to provide the necessary care for future patients. The impending surge (at the time of this writing) also threatens our patients with a lack of ventilators for the ICUs. Fortunately, American ingenuity and a “can do” attitude is rising to the challenge. 

In times such as now, we all need courage—the courage to persevere, to serve, and to honor our commitment to our patients and our profession. Although the winds and waves of the world are bashing against us, take heart. Have an anchor. Social distancing does not mean spiritual distancing. Be strong and keep the faith. I look forward to seeing you all, each and every one of you, again soon!

COVID-19 Public Health Update

by Catherine Colquitt, MD

In December 2019, the world learned of a new Coronavirus called SARS-COV-2, causing the disease COVID-19 in which patients were experiencing respiratory illness and death in Wuhan City, Hubei Province, China.  

Since then, we have been deluged with information about the virus, its epidemiology and transmission, its target populations, and its effects on new human hosts. COVID-19 has captured the attention of most of the world.    

We have learned much in the last few months. The viral genome has been sequenced, permitting development of diagnostic tests and paving the way for development of vaccines and antiviral therapies. Several excellent sources of curated scientific data regarding
COVID-19 became indispensable in our understanding of the rapidly changing guidance regarding how best to respond to challenges posed by the new virus.  

These sources include the Johns Hopkins COVID-19 website, which updates worldwide data on cases and deaths in real time; the World Health Organization (WHO) COVID-19 website, which updates daily and has been prolific in issuing and amending guidance on measures designed to blunt the impact of COVID-19 worldwide; and the Centers for Disease Control (CDC) COVID-19 website, which was for several weeks the only outlet for testing in the U.S., and whose guidance is crafted with U.S. healthcare workers, other affected workers, and the broader public in mind.  

As of April 27, 2020, per the Johns Hopkins COVID-19 site, there were more than 3,000,000 confirmed cases globally, and 208,131 COVID-19 deaths worldwide, with more than 993,103 confirmed U.S. COVID-19 cases and 55,729 COVID-19 U.S. deaths. For reference, on March 25, 2020, Johns Hopkins reported 54,000 U.S. COVID-19 cases and 787 U.S. COVID-19 deaths.    

With no proven effective treatments or vaccines yet available to curb
COVID-19’s worldwide impact, controlling the virus remains focused on time-tested communicable disease control measures. These include social distancing, hand hygiene, respiratory etiquette, staying home if ill, cancellation of mass gatherings, school closures, and the shuttering of nonessential services and retail establishments.  

Against this background, healthcare providers and patients struggle to keep up with voluminous and changing guidance and filter out the cacophony of misinformation which has dominated some corners of the internet and other outlets.  

Testing has been difficult in many places, including the U.S., due to a shortage of test kits (swabs and viral transport media) and reagents required for testing. In the U.S., only the CDC’s Atlanta laboratory could test initially, and results could take several business days. Eventually state labs were authorized to test and the Tarrant County Public Health North Texas Regional Laboratory (a Laboratory Response Network facility) began conducting tests using a two-target real-time polymerase chain reaction assay developed at the CDC. Commercial laboratories are now online with testing as well, facilitated by FDA emergency use authorizations to address scarcity of testing capacity.  

 With schools and many businesses closed, our lives have been altered, and we all know people stressed by the measures implemented to curb the spread of COVID-19 in Tarrant County. Frustration and fear of COVID-19 have been felt throughout our country and across the world. 

We have also watched the devastating effects of COVID-19 on populations and healthcare infrastructure in Washington, California, New York, and elsewhere. Tarrant County Public Health and its partners are assisting with the
COVID-19 response, investigating cases and contacts, in hospitals, long-term care facilities, correctional institutions, and other settings. (COVID-19 is especially threatening to the elderly, and persons with diabetes, heart disease, underlying pulmonary conditions, and immunosuppression).  

Tarrant County Public Health and our neighbors have confirmed community spread of COVID-19 in persons with none of the previously identified COVID-19 risk factors, including travel to endemic areas or contact with a known case.  Tarrant County has recorded 53 COVID-19 deaths so far.  On March 25, 2020, that number was two.  

Many facets of COVID-19 responses have been frustrating, and guidance has changed frequently and materially at times throughout our short history with this virus, but reliable sources of information continue to be the CDC, Johns Hopkins, and the WHO.  

The CDC’s Coronavirus 2019 Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings is a highly readable document which emphasizes three key messages: 

  1. Decreasing traffic throughout healthcare facilities;
  1. Isolating symptomatic patients as soon as they are flagged through screening procedures;
  1. Protecting healthcare workers and other frontline workers by limiting staff caring for COVID-19 patients; prioritizing respirator masks and airborne infection isolation rooms, or negative pressure rooms where possible.

Most of us are old enough to remember at least one recent outbreak, but COVID-19 will be noteworthy in our history for the scale of its disruption of our lives and work, and for the lessons we learned about how to better prepare for the next such crisis.