Dr. Vivek Murthy Champions the Power of Togetherness

In our youth and middle age, we all wish a long and healthy life to our family and friends, no more so than at this holiday season.  We pause now between Christmas and New Year during winter's annual break.

As we age and have expectancies of our golden years that may or may not be realistic, how many of us could not save for retirement due to illness, disability, never-ending family responsibility, catastrophic events such as floods, tornadoes, firestorms, or hurricanes, most Americans will come up short in their savings plans.  Very few people begin savings early.  Even well educated people with good incomes now service huge education debt in line with what used to be a mortgage payment.  Housing costs have become ridiculous, and despite recessions, the pandemic real estate values continue to outpace inflation. Add to this is a housing shortage.  The housing market is very much divided.  There seems to be no shortage in t he market for the wealthy. 

As we age if you are unfortunate enough to outlive family and friends our support group shrinks and may disappear.  We become dependent upon social organizations, assisted living and/or care at home.  Some cannot afford those 'luxuries' and must manage 'alone, with devastating effects on health and emotional wellness.  It is a gradual decline, sometimes not noticed by those around the aged.

I often hear people saying I don't want to outlive my bank account.

As a physician and as Surgeon General, Murthy found that loneliness was a profound problem that can lead to public health concerns from addiction to depression, yet it was rarely discussed.

Dr Murthy wrote,

Together: The Healing Power of Human Connection in a Sometimes Lonely World.

Dr. Vivek Murthy: What's really interesting is that there are many manifestations of loneliness in any age group. And this is why loneliness can often be so invisible, including among those who are older, because we stereotypically think about loneliness as the person who is living alone at home and has no one coming to visit, or the person who is living in an institution and no family ever stops by. 

"If there's a gap between the connections you feel you need and the connections you have in your life, then you can feel lonely regardless of how many people you have around you." 

But I call it the great masquerader because it can look like depression, it can look like anxiety. Loneliness can look like anger and irritability, which is often how it shows up among men in particular, but also sometimes among women. It can look like being socially withdrawn. It can look like being bored and disinterested. 

And when you start to think about that broader context then you start to realize, gosh, I might actually know a lot of people who might be struggling with loneliness. It doesn't mean that everyone who is depressed is lonely, it doesn't mean that everyone who has anger issues is lonely. But I have found more often than not that loneliness is contributing to many of these feelings. 

We need to define the difference between loneliness and isolation.  Isolation is an objective term that describes the number of people we have around us. Loneliness is a subjective term that describes how we feel about the connections we have in our life. And if there's a gap between the connections you feel you need and the connections you have in your life, then you can feel lonely regardless of how many people you have around you. 

A couple of studies have found that older adults are actually in general doing better emotionally during the pandemic.  

Dr. Vivek Murthy Champions the Power of Togetherness | Next Avenue

Type of mask matters for COVID-19 protection. – Scientific Inquirer

Not all Covid Masks are equal, There is a lot of hype and fake news about masks. The demand for masks has attracted shrewd marketers and outright frauds. The gold standard remains the N95 or KN95.  The homemade variety and fashionable masks may or may not satisfy the requirements to block particles less than 2.5 microns, which is the standard for N95 masks.

                                    Best                             Not as Safe             Useless for COVID

Even though it has been widely known that wearing a face mask will help mitigate the community spread of COVID-19, less is known regarding the specific effects of masks in reducing the viral load in the respiratory tracts of those wearing them. In Physics of Fluids, by AIP Publishing, researchers from the University of Massachusetts Lowell…and California Baptist University examined the effect of wearing a three-layer surgical mask on inspiratory airflows and the mask’s effects on the inhalation and deposition of ambient particles in the upper respiratory airways. “It is natural to think that wearing a mask, no matter new or old, should always be better than nothing. Our results show that this belief is only true for particles larger than 5 micrometers, but not for fine particles smaller than 2.5 micrometers,” said author Jinxiang Xi.

The researchers found that wearing a mask with low (less than 30%) filtration efficiency can be worse than without.

They developed a computational face mask model using a physiologically realistic model of a person wearing a surgical mask with pleats and then using numerical methods to track the particles through the mask. They examined the behavior and fates of aerosols passing through the mask, onto the face, into the airway, and, eventually, where they deposit in the nose, pharynx, or deep lung.

The model showed a mask changes the airflow around the face, so that instead of air entering the mouth and nose through specific paths, air enters the mouth and nose through the entire mask surface but at lower speeds.

The lower speed near the face favors the inhalation of aerosols into the nose, so even though masks filter out certain numbers of particles, more particles escaping mask filtration can enter the respiratory tract.

The video clearly elaborates on what type of mask you should be wearing.

Despite warnings about distancing sanitizing and mask-wearing the pandemic is presently in an explosive phase (logarithmic). This is undoubtedly caused by holiday activities.  The fact is that even if you invite only family you are at risk of contracting COVID 19.

Chris Christy, Governor of New Jersey confessed on CNN how wrong he was about wearing masks. He was caught up in political expediency during an election cycle. Christy explained how everyone was tested at the Republican event at the White House.  He was told everyone was tested and could only enter if testing was negative.  This raises serious questions about rapid testing and if it is reliable.  The results speak for themselves.  

There are almost as many opinions about wearing masks.  Infection rates were very high in Texas since many people would not wear masks, businesses remained open and life was about 80% of pre-Covid times.  Ross Perot gave an interesting assessment of Texas' economy

The virus is out there.

You can find the complete report below

Type of mask matters for COVID-19 protection. – Scientific Inquirer: 

To Vaccinate or not to Vaccinate

That is the question, and the answer is a definite and resounding yes.   There are many 'anti-vaxxers' out there.  No matter what the vaccine their clear message is 'hell no, I won't go' or over my dead body (and that can happen)

Even if you have had previous vaccines and had a reaction, the COVID19 vaccine is a totally new game in town.  It does not use a whole viral particle, live, or deactivated. The covid protein spike cannot reproduce. It is not grown in an egg or any other living cell.  There is little to no chance of an allergic reaction.  

There are many reasons to get the vaccine. For your own protection, to prevent someone else who may be at risk of death due to age, compromised immunity or chronic health issues.  Children are important as well even though most do not get very sick or even have symptoms, and just carriers.  Children represent a large viral pool in the general population and will spread it to other children and adults.

No one has mentioned that SARS viruses mutate often, at times into even worse viral pathogens.  The more viral divisions, the greater the chance of a harmful genetic mutation.  The longer the pandemic lasts the increased chance of another even more severe novel Corona Virus.  How much time we have, no one really knows.  SARS outbreaks occur at 10-15 year intervals from past experience. But not one can be certain.

In addition to the usual concerns, there is a new excuse for not vaccinating. This has to do with the new manufacturing process using messenger RNA.  There is some confusion.  Some patients think that Messenger RNA is being injected into humans and the vaccine is generated in our own cells. There is concern that this is human genetic engineering. There are no human genes involved.

Messenger RNA is not injected into humans.  The only substance injected is the coronavirus protein spike which is manufactured in a laboratory container filled with the correct amino acids and a specific mRNA to construct an artificial protein spike. 

The artificial covid spike is so unstable that it must be kept very cold in order to prevent it from degrading. Not only do the amino acids have to be in the correct sequence the protein must be in a specific 3D shape held together by the bonding of the amino acids in order to be active.  Scientists have been at work developing the technique for more than 25 years.

The FDA consults with scientists who have no conflicting interest and who review all the literature dating back to the seminal articles of DNA, RNA, proteomics, and manufacturing processes down to inspection of pharmaceutical plants. The FDA has enforcement authority to shut down any plant not meeting their regulations for deviations from the manufacturing process, lack of sterility, and more. The process is exhaustive.

The Manufacturing Sounds of a Virus

Marcus Buehler's Sound Cloud Music of Virus Production

What is messenger RNA ?

Graphic Representations of Covid 19 Vaccine Production

Covid19 spike configuration

How it works

Tracking the Development of COVID19 Vaccine

Thousands of scientists were involved in developing a safe and effective vaccine. This groundbreaking development is a catalytic innovation and a paradigm shift for vaccine production reducing the process from several years to several months.

And the winners are:  BionTech/Pfizer and Moderna

Covid 19 Depression ?

How are you coping with almost a year of social distancing, wearing a mask, and not being able to use many facilities such as gyms, restaurants, clubs, and more?  Those who seem to be coping the best have already established routines of meditation, yoga, exercise routines, and eating a healthy diet.

Health Train Express today is focusing on mental health, whether it is depression, anxiety or fear. All of those are a natural outcome of what we all have experienced with COVID 19.  This may have affected young people even more than adults or older people. Children and adolescents are highly social in a critical time of development learning to socialize and deal with adolescent anxiety and changes.  Most of these ideas will help you and your kids.  Arrested social development can be a serious long term outcome of COVID19, as schools are closed.  Remote learning is not suitable for children who complain they miss their friends.

Health Train Express does not usually endorse specific products, however today we are making an exception, and the reason is a unique partnership with Synctuition. This partnership will promote Health Train Express on their site, and also some of their content will appear here today and in the future.

Here is a sample of their content:

Like any other major, worldwide events, the COVID-19 crisis has forever changed our routines and the way we see life. It has also reshaped our romantic relationships. As several nations across the world slowly emerge from lockdown, we reflect on the way we’ve been separated from our loved ones or been obliged to live in close proximity with our partners. Every experience has been unique, but it has raised some concerns. 

For some, the high confinement has created tensions and caused serious conflict. In March, for example, China saw a dramatic peak in divorce requests. Something similar has happened in other European nations. 

However, this is not something exclusive of the current health emergency. Romantic relationships are hard work. With everything going around you — your career, children, hobbies, and personal goals — it’s easy to lose sight of how much you care about your significant other. Especially when you’re going through a rough patch. 

Leave a comment or give it a thumbs up or down.  You also will find more information on their Facebook page

https://app.synctuition.com/

Inside the Lab That Invented the COVID-19 Vaccine

Perhaps this scientist should have been Time Magazine's "Man of the Year"

Not enough Pfizer vaccine doses? Blame the feds, not the company: reports | FiercePharma

Just as thousands of Brits were lining up to get Pfizer’s mRNA COVID-19 vaccine yesterday, a troubling question emerged in the U.S.: Did the United States government fail to lock in enough doses of the vaccine to ensure a broad and quick rollout here?

The short answer appears to be yes.   The long answer is no.  Health Train Express theorizes that this was no accident.  The Feds were hedging their bet on both Pfizer and Moderna. Even with a successful clinical trial, there are many variables that can go wrong.  Many months ago when the bidding process began there was uncertainty if either pharmaceutical company would deliver a successful vaccine or whether the FDA. would grant a EUA to one, or both companies. 

Not being able to read the actual contracts I am stepping out here with my thoughts.  The entire vaccine development process is complex and adding to it is the cryopreservation for the Pfizer candidate vaccine adds logistics.  The first question is will it store?  Other factors are what would happen if a cryo storage warehouse failed?  There would need to be multiple storage warehouses (ie backup) to prevent this from occurring.

 

Federal contracts are complex and have opt-out, waivers, and cost overruns as part of the contract. If it is anything like military contracts they are developed to mitigate losses by the government taxpayers and prevent insolvency on the part of the manufacturer.  In the past, we have all read about the pitfalls in developing experimental aircraft, and military weapons.

Is it really important that 100 million doses be delivered at the outset? What is the difference between 50 and 100 million doses?  That is an unknown metric. Another variable is we do not know if permanent immunity will occur or for how long.  Since the clinical trial was abbreviated to insure a safe vaccine, it was a relatively short clinical trial. The next 12 to 24 months will determine how and if immunity results.

The pandemic is far from over and another cycle will begin in 2021,  If the federal government had ordered 100 million doses and it turned out the immunity was poor, or short-lived a considerable amount of your taxpayer dollars would go down a biological waste dump.    

In addition to contracts with Pfizer/BioNet the U.S.A has contracts with Moderna.  Vaccines will be available from both sources.  

Ultimately there will be enough vaccines to go around the globe. 

Not enough Pfizer vaccine doses? Blame the feds, not the company: reports | FiercePharma

NOT A DOCTOR, JUST AN M.D.

Even during normal times, there are not enough doctors.  We have more than enough M.D.s, however, some chose not to take care of patients, for one of many reasons.  Any person who receives an M.D. has passed 3 levels of examination, but are required to complete on the job training in an internship and one of the multiple specialty residencies.  It is an arduous task, using a matching program, traveling to interview while still attending medical school.  It is also expensive to travel, and most graduates are poor and already in debt.

Anyone who graduates is intellectually qualified to be a doctor.  However, an M.D. without postgraduate training cannot be licensed to practice medicine.  The sad fact is there is a shortage of residency positions leaving many M.Ds without a suitable hospital to complete training.  Some will choose to study for an M.B.A., or become a research scientist, earn a Ph.D., or become a consultant.  

The process is highly competitive and there are several tiers of hospitals that train physicians, including academic medical centers, community hospitals, government hospitals, (military, VA,)

I matched

Here is a moving story of one physician:

The story is taken from the blog "NOT A DOCTOR, JUST AN M.D."

When March approached I start to build an undesirable and familiar feeling deep in my chest. The closer it gets to mid-March,  known as Matchday,  it grows in me like a tumor. This year, I thought I would escape that feeling by not applying to the match. Yet, the feeling crept up like an unwanted weed and grew. I saw others who were unmatched last year celebrating their success of getting into residency programs across the United States. As I read about my colleagues matching, I had to hold back the tears so as not to dampen their joy. I hoped that I could overcome it but I all my tears flow from the same source. 

 I received one interview last year after I had written every Family Medicine, Psychiatry, and Internal Medicine program director in the nation. I finally found a program director that had an open heart and was willing to take a chance. This was a high-stakes interview and I prepared for it every day. The day of the interview, my disabling test anxiety and exacerbated ADHD took hold of me and I was not selected. This year I did not even try to get into a residency. Sometimes I get an occasional email or message telling me about an open internship. I quickly get all my information in an email to the program, then never hear anything back. I didn't apply to the match this year. There was no point.

I want to be inspirational. I want to be positive. I have always tried so hard, yet the accumulation of persistent rejection and the mantra of: "you don't deserve to practice medicine" or "you didn't earn the right to be called the doctor" echoes in my ears and paralyzes me. 

Another colleague that I work with has created a ritualistic way of dealing with his matchday rejection. He videotapes himself talking about his hopes and fears, his sadness. Others get angry and bitter. We are all cycling through the stages of grief, and it is a long road to acceptance. 

I am still hearing the myth that unmatched graduates can do research or work in Information Services (IS) as a "back-up". Most people in the medical profession want to believe that a graduate physician has a chance out there in the world. There is a small percentage of people who do go into research. I have found the IS consultant job to be something. Consultancy positions are filled with unmatched graduates (mainly IMGs) who never went to residency or residents that never completed their program. Some colleagues have coined our group "The Undesirables".  We train practicing physicians on Electronic Health Record (EHR) programs such as Cadence or EPIC. They often look at us curiously and wonder why we would be doing this job instead of practicing medicine. All the Is consultants have a "story" to tell. Nobody confesses the truth of being unmatched. We don't disclose that we never actually went into residency because it is taboo in this unique world of EHR "Go-Lives". Honestly, most of us are shamed by our failures. 

Now those with boots on the ground will opinionate (those who accept MDs into graduate programs will say, "We get hundreds or even thousands of applicants for our residency programs. We must use some objective measures to filter our acceptances." Good, but not good enough".

This is not just the observation of a disappointed M.D. and it is not an uncommon barrier

Failure to Match Category

6% US MD           1st time

56% US MD           2nd time

21% US DO

29% Canadian MD

47% International MD (US Resident)

51% International MD (Non-US Resident)

Medical School Admissions is responsible for some of the problems. 

Failures All-Around

First, she failed. Medical school isn't easy, and residency is harder. She failed Step 1. Secondly, she was a foreign medical graduate. There are some FMG schools that do rank highly for acceptance at U.S Hospitals.  There are also less desirable post graduate training institutions located in less desirable regions of the United States. This was a deadly combination for this student. Every medical student is well aware of the importance of that test. The goal isn't just to pass it so you can graduate from med school, it's to rock it so you can get into a good residency program. Passing it is generally taken for granted by most medical students. She failed at the residency matching game (i.e. applying to enough programs that might really take you to match into one of them)…twice. It's not like there is one person out to get her. 200 program directors, presumably some of whom are desperate to fill their class in their new, on-probation, or failed-to-fill-last-year programs, and including her home program, took a pass on her. I suspect these issues were also reflected in her letters, essays, and interviews. There are many other things to criticize about her past decisions and writing, but that's not the point of this post so let's leave it there. The point is med school is hard, and it takes a lot of hard work, smarts, “ability to pass tests,” and the ability to communicate well and interact well with others. No matter how the system changes or how medical schools change their policies, some people are going to fail. However, many docs are surprised (I was) to learn how high these statistics are. Just looking at the US MD Match, these are the stats:

Failure to Match Category

6% US MD           1st time

56% US MD           2nd time

21% US DO

29% Canadian MD

47% International MD (US Resident)

51% International MD (Non-US Resident)

Second, her school admissions committee failed her. For some reason, the school felt she should be in that class of med students. Who knows exactly why, but they felt she was academically “good enough” (despite an MCAT of 24) and could contribute something to the class. In retrospect, they screwed up. She wasn't academically “good enough.” She couldn't pass step 1 (the first time.) She couldn't make up for it enough elsewhere to match (despite reportedly applying to 200 programs.) Now, OHSU has her money and she has debt that will, at best, be forgiven 10 years from now. Medical schools should be required to provide these sorts of statistics to their applicants. At least then they'd know what kind of a gamble they were making before they plunked down their $400K (as you can see it's a real gamble for most international schools.) The real task for a medical student isn't to get an MD, it's to get a residency spot. Neither students nor schools should ever forget that. While I suppose I expect DOs in the MD match to have a lower match rate (at least they have the DO match as a back-up), and international medical grads usually know they're gambling a bit, even 6% is way too high and 50% after hundreds of thousands in tuition is insane! When a student gets an MD but not a residency, both student and school have failed. Maybe half the tuition ought to be refunded or something aside from very prominent disclosure of these statistics. Too bad there isn't some insurance product out there that schools could purchase to at least wipe out some or all of the debt for their non-matches. They could market it as a “guaranteed match or $100K back!” If med schools are going to be “for-profit” they might as well run them like any other business.

Third, the system failed her. She is absolutely correct in her criticism of the system. 1,000 US med students a year and 2,400 US Citizen IMG med students each year don't match. They have the same debt as anyone else but don't have the income. She advocates for more residency spots to help the “doctor shortage.” Maybe that's part of the answer (probably not for her though, since there were apparently programs willing to not fill rather than take her.) Maybe it's fewer med school spots or tighter academic admissions standards. Maybe it is to allow residencies to pay the best candidates more and to allow the worst candidates to pay for the privilege of training and let market forces solve the issue. I don't know. But I do know there are 3,400 people a year coming out of med school with hundreds of thousands of dollars in debt they won't be able to pay back, and that's a problem. Each of those doctors has a personal financial catastrophe to deal with.  

Other things to think about

So next time you see your " Doctor " remember he is not just an M.D. but a "Doctor" A doctor is not just an M.D. he has been trained by other clinicians and judged accordingly. Today it is necessary to become board certified in a specially.  Even the good old GP or Family Medicine Doc must pass a written and oral examination given by a specialty board in their specialty.

When I attend social events many people who I consider close friends will address me as 'Doctor Levin".  I am still surprised by that, and it makes me realize who I am, not that I am 'better' than them. It makes me realize there are still people who respect me more than I do myself.

So, what is my call to action? I implore you to write your senators, write your legislators, wrote everyone who you think can make a change, and let them know that there are thousands of unemployed doctors who would love to practice medicine. We just need more residencies.

If you have comments or suggestions please leave them in the comment section.

Remember to wear your mask and distance from others.