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THCB Gang, Episode 11

Episode 11 of “The THCB Gang” was live-streamed on Thursday, May 27th and you can see it again below

Joining me were three regulars, patient safety expert Michael Millenson (MLMillenson), writer Kim Bellard (@kimbbellard), health futurist Ian Morrison (@seccurve), and two new guests: digital health investment banker Steven Wardell (@StevenWardell) and MD turned physician leadership coach Maggi Cary (@MargaretCaryMD)! The conversation was heavy on telemedicine and value based care, and their impact on the stock-market, the economy and the health care system–all in a week when we went over 100,000 deaths from COVID-19.

If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt

THCB Spotlights: David Smith, Medicaid Transformation Project at Avia

By ZOYA KHAN

Matthew Holt talks to David Smith who is working on the Medicaid Transformation Project at Avia, which is looking at how hospitals & health plans can improve health outcomes and in turn, lose less money on Medicaid programs. David talks about the tremendous amount of capital being poured into Medicaid, and how the problem is only getting worse. So the focus of the project is trying to reduce healthcare delivery organizations’ spend on these services. At Avia, they are trying to take the best of model science and the best of digital capabilities to help create more efficient care models for their clients as well as reduce costs.

Zoya Khan is the Editor-in-Chief of THCB and a Strategy Manager at SMACK.health

The Problem With “Herd Immunity” as a COVID-19 Strategy

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By e-PATIENT DAVE DEBRONKART

Caution: This post is not a prediction. It’s just a tutorial about the concept of herd immunity, with an eye to why it’s probably not an approach the US wants to take in solving the complex problems we’ve gotten ourselves into with COVID-19.

Click this graphic to go see a six second animation of these images, created in 2017 by Reddit user TheOtherEdmund. You many need to watch a few times. Get a feel for the differences in what happens in the different blocks, and come back to discuss:

This weekend I’ve labored to understand this concept, which first came to my ears regarding coronavirus in March, when British prime minister Boris Johnson proposed it as a possible approach for Britain to take: let the virus take its course, and they’d end up with “herd immunity,” and that would be the end of that.

In my unsophisticated knowledge “herd immunity” meant “you let the weak cows die, and the rest of the herd will be fine.” And in fact in April a Tennessee protestor held up a sign saying “Sacrifice the Weak – Reopen TN.” (It’s not clear whether the sign was mocking or real (Snopes), but it illustrates the point.)

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COVID-19 and Opening the Country: Lessons from 1918 Philadelphia

By CHADI NABHAN, MD, MBA, FACP

Everyone has an opinion on whether and when we should open the country. Never in the history of America have we had so many “correct” theories and experts to pontificate on a new pandemic. But somehow, few seem to recall history or attempt to learn from it.

Over a century ago, almost 100 million people out of a world population of 1.8 billion lost their lives to the so-called “Spanish Flu”. At 8.5 million casualties, the death toll from World War I pales in comparison. In the US alone, we lost over 675,000 people in one year to this pandemic. In fact, we lost more people to the 1918 flu than to World War I, World War II, the Korean War, and the Vietnam War combined. It was estimated that 5-10% of young adults had died. Nothing has ever come close in devastating the world’s population.

In early 1918, Dr. Miner from Haskell County in Kansas encountered several patients with a severe form of the flu that faded away by March 1918. He was concerned enough to report his observations to the US public health services, who published his concerns but then ignored the issue; there were more pressing problems facing the world, namely World War I. But in Camp Funston, a military complex, soldiers were faced with such cold weather and inadequate clothing that 7,000 of them suffered from the flu and nearly 100 died. Still, these warning signs didn’t seem alarming enough to prevent 1.5 million soldiers from crossing the ocean and going to war in Europe.

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COVID-19: Physicians in Shackles

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By ANISH KOKA, MD

A number of politically tinged narratives have divided physicians during the pandemic. It would be unfortunate if politics obscured the major problem brought into stark relief by the pandemic: a system that marginalizes physicians and strips them of agency.

In practices big and small, hospital-employed or private practice, nursing homes or hospitals, there are serious issues raising their heads for doctors and their patients.

No masks for you

When I walked into my office Thursday, March 12th, I assembled the office staff for the first time to talk about COVID.  The prior weekend had been awash with scenes of mayhem in Italy, and I had come away with the dawning realization that my wishful thinking on the virus from Wuhan skipping us was dead wrong.  The US focus had been on travel from China and other Far East hotspots.  There was no such limitation on travel from Europe.  The virus had clearly seeded Italy and possibly other parts of Europe heavily, and now the US was faced with the very real possibility that there was significant community spread that had occurred from travelers from Europe and Italy over the last month. I had assumed that seeing no cases in our hospitals and ICUs by early March meant the virus had been contained in China.  That was clearly not the case.

Our testing apparatus had also largely been limited in the US to symptomatic patients who had been to high-risk countries.  If Europe was seeded, this meant we had not been screening nearly enough people.  When I heard the first few cases pop up in my county, it was clear the jig was up.  It was pandemic panic mode time.  There was a chance that there were thousands of cases in the community we didn’t know about and that we were weeks away from the die-off happening in hospitals in China and Italy.  So what I told the staff the morning of March 12th was that we needed to start acting now as if there was significant spread of COVID in the community.  This meant canceling clinic visits for all but urgent patients, wearing masks, trying to buy masks, attention to hand hygiene, cleaning rooms between patients, screening everyone for flu-like symptoms before coming to the office, and moving to a skeleton staff in the office.  I left the office that day wearing a mask as I headed to the ER.

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Hiding Our Heads in the Sand

By KIM BELLARD

There are so many stories about the coronavirus pandemic — some inspiring, some tragic, and all-too-many frustrating.  In the world’s supposedly most advanced economy, we’ve struggled to produce enough ventilators, tests, even swabs, for heaven’s sake.  

I can’t stop thinking about infrastructure, especially unemployment systems.

We’d never purposely shut down our economy; no nation had.  Each state is trying to figure out the best course between limiting exposure to COVID-19 and keeping food on people’s tables.  Those workers deemed “essential” still show up for work, others may be able to work from home, but many have suddenly become unemployed.

The U.S. is seeing unemployment levels not seen since the Great Depression, and occuring in a matter of a couple months, not several years.  As of this writing, there are over 22 million unemployed; no one believes that is a complete count (not everyone qualifies for unemployment), and few believe that will be the peak.

Many unemployment systems could not manage the flood of applications.  

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Is the COVID-19 Antibody Seroprevalence in Santa Clara County really 50-85 fold higher than the number of confirmed cases?

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By CHRISTOS ARGYROPOULOS

I am writing this blog post (the first after nearly two years!) in lockdown mode because of the rapidly spreading SARSCoV2 virus, the causative agent of the COVID19 disease (a poor choice of a name, since the disease itself is really SARS on steroids).

One interesting feature of this disease is that a large number of patients will manifest minimal or no symptoms (“asymptomatic” infections), a state which must clearly be distinguished from the presymptomatic phase of the infection. In the latter, many patients who will eventually go on to develop the more serious forms of the disease have minimal symptoms. This is contrast to asymptomatic patients who will never develop anything more bothersome than mild symptoms (“sniffles”), for which they will never seek medical attention. Ever since the early phases of the COVID19 pandemic, a prominent narrative postulated that asymptomatic infections are much more common than symptomatic ones. Therefore, calculations such as the Case Fatality Rate (CFR = deaths over all symptomatic cases) mislead about the Infection Fatality Rate (IFR = deaths over all cases). Subthreads of this narrative go on to postulate that the lockdowns which have been implemented widely around the world are overkill because COVID19 is no more lethal than the flu, when lethality is calculated over ALL infections.

Whereas the politicization of the lockdown argument is of no interest to the author of this blog (after all the virus does not care whether its victim is rich or poor, white or non-white, Westerner or Asian), estimating the prevalence of individuals who were exposed to the virus but never developed symptoms is important for public health, epidemiological and medical care reasons. Since these patients do not seek medical evaluation, they will not detected by acute care tests (viral loads in PCR based assays). However such patients, may be detected after the fact by looking for evidence of past infection, in the form of circulating antibodies in the patients’ serum. I was thus very excited to read about the release of a preprint describing a seroprevalence study in Santa Clara County, California. This preprint described the results of a cross-sectional examination of the residents in the county in Santa Clara, with a lateral flow immunoassay (similar to a home pregnancy kit) for the presence of antibodies against the SARSCoV2 virus. The presence of antibodies signifies that the patient was not only exposed at some point to the virus, but this exposure led to an actual infection to which the immune system responded by forming antibodies. These resulting antibodies persist for far longer than the actual infection and thus provide an indirect record of who was infected. More importantly, such antibodies may be the only way to detect asymptomatic infections, because these patients will not manifest any symptoms that will make them seek medical attention, when they were actively infected. Hence, the premise of the Santa Clara study is a solid one and in fact we need many more of these studies. But did the study actually deliver? Let’s take a deep dive into the preprint.

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Lessons from Zika in the Era of COVID-19

By CHADI NABHAN, MD, MBA, FACP

If you are a soccer fan, watching the FIFA World Cup is a ritual that you don’t ever violate. Brazilians, arguably more than any other fans in the world, live and breathe soccer—and they are always expected to be a legitimate contender to win it all. Their expectations are magnified when they are the host country, which was the case in 2014. Not only did the Germans destroy Brazilian World Cup dreams, but less than a year after a humiliating loss on their turf, Brazilians began dealing with another devastating blow: a viral epidemic. Zika left the country scrambling to understand how to manage the devastation caused by the virus and grappling with conspiracies theories of whether the virus was linked to the tourism brought by hosting the FIFA World Cup.

How did I become so interested in what happened in Brazil five years ago? Well, social distancing and being mostly at home in the era of COVID-19 seems to energize reflection. Watching politicians on TV networks blaming each other and struggling to appear more knowledgeable than scientists makes me marvel at the hubris. My mind took me back to several prior epidemics that we encountered from Swine Flu to Ebola, and I couldn’t help but think about the lessons lost. What did we miss in these previous crises to land us in this current state where Zoom is your best friend and you are more interested in commenting on tweets than doing a peer-review? One cannot help but wonder what is so different about this coronavirus that it has paralyzed the globe.

I decided to take a deep dive into the Zika epidemic in a hopeful effort to better understand the present public health crisis. I started by reading Zika: The Emerging Epidemic, by Donald G. McNeil Jr, who also covers global epidemics for the New York Times. The book is a fascinating read and offers illuminating parallels to the current failings we are seeing with national and global health protection agencies during the COVID-19 pandemic.

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Provide Emotional Personal Protective Equipment (PPE) for Physicians Facing Psychological Trauma From the COVID-19 Crisis

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By SUZAN SONG MD, MPH, PhD

The U.S. now has the highest number of COVID-related deaths in the world, with exhausted, frightened physicians managing the front lines. We need not only medical supplies but also emotional personal protective equipment (PPE) against the psychological burden of the pandemic.

As a psychiatrist, my role in COVID-19 has included that of a therapist for my colleagues. I helped start Physician Support Line, a peer-to-peer hotline for physicians staffed by more than 500 volunteer psychiatrists. Through the hotline and social media, physicians are revealing their emotional fatigue. One doctor shared her sense of powerlessness when she couldn’t provide comfort but instead had to watch her young patient with COVID-19 die alone from behind a glass window. Another shared his sorrow after his 72-year-old patient died by suicide. She was socially isolated and didn’t want to be a burden on anyone if she contracted COVID-19. An internist felt deep distress and alarm that her hospital was quickly running out of ventilators and had 12 codes in 24 hours. 

Through a brief survey I conducted across the U.S., 269 physicians reported moderate to severe symptoms of anxiety (53%), depression (43%), and insomnia (16%). About 46% wanted to see or would consider seeing a mental health clinician for severe anxiety (30%), not feeling like themselves (27%), or being unhappy (21%). These are all similar statistics to the front line health care workers in Wuhan. 

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The Official Estimates of COVID-19 Deaths Are Way Too Low

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By KEN TERRY

While President Trump mulls whether to reopen the country again in May, and as Fox & Friends host Brian Kilmeade suggests that “only” 60,000 people will die from the coronavirus, there are some warning signs that the White House COVID-19 Task Force’s prediction of 100,000-240,000 deaths may be way too low.

That isn’t surprising, considering that Administration officials said this projection depended on us doing everything right. Of course, it appears that large sections of the country have done many things wrong—whether it’s Florida Governor Ron DeSantis’ reluctance to close houses of worship or the refusal of several state governors to issue stay at home orders. That doesn’t include Trump’s own refusal to admit the seriousness of the COVID-19 outbreak until mid-March and the continuing failure of the federal government to ensure an adequate supply of test kits, PPE and ventilators.

So here’s what all of this may be leading up to: a minimum of 600,000 COVID-related deaths in the U.S. over the next two years.

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