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.

See How Coronavirus Restrictions Compare to Case Counts in Every State - The New York Times

Coronavirus cases are rising in almost every U.S. state. But the surge is worst now in places where leaders neglected to keep up forceful virus containment efforts or failed to implement basic measures like mask mandates in the first place, according to a New York Times analysis of data from the University of Oxford.

Using an index that tracks policy responses to the pandemic, these charts show the number of new virus cases and hospitalizations in each state relative to the state’s recent containment measures.

States That Imposed Few Restrictions Now Have the Worst Outbreaks

Outbreaks are comparatively smaller in states where efforts to contain the virus were stronger over the summer and fall — potential good news for leaders taking action now. States and cities are reinstating restrictions and implementing new ones: In recent days, the governors of Iowa, North Dakota and Utah imposed mask mandates for the first time since the outbreak began.

The index comes from Oxford’s Blavatnik School of Government, where researchers track the policies — or lack thereof — governments use to contain the virus and protect residents, such as contact tracing, mask mandates and restrictions on businesses and gatherings. Researchers aggregate those indicators and assign a number from 0 to 100 to each government’s total response.

At its highest level of containment efforts, New York state scored an 80 on the index. At the beginning of November, most states were scoring in the 40s and 50s. Though many have taken fresh steps to contain the virus since then, the Times analysis compares cases and hospitalizations for a given date to a state’s index score from two weeks before, since researchers say it is reasonable to expect a lag between a policy's implementation and its outcome.

Most states imposed tight restrictions in the spring even if they did not have bad outbreaks then. After reopening early, some Sun Belt states, including Arizona and Texas, imposed restrictions again after case counts climbed. Now, Midwestern states have among the worst outbreaks. Many have also done the least to contain the virus.

A relationship between policies and the outbreak’s severity has become more clear as the pandemic has progressed.

“States that have kept more control policies in a more consistent way — New England states, for example — have avoided a summer surge and are now having a smaller fall surge, as opposed to states that rolled them back very quickly like Florida or Texas,” Mr. Hale said. “I think timing really matters for the decisions.”

The worst outbreaks in the country now are in places where policymakers did the least to prevent transmission, according to the Oxford index. States with stronger policy responses over the long run are seeing comparatively smaller outbreaks.

While we have contrived to control the pandemic, some things seem certain.

1. A continuing and consistent quarrantine, social distancing and masking are mandatory. Pop-up attempts at lockdown measures implemented locally or regionally may not alter the long term goal of decreasing morbidity and/or mortality, nor improve the economic effect.  Playing catch up management cannot be communicated effectively and may be a waste of resources.

2. There have been reports of health system executives leading the efforts for containment and treatment with inconsistent results.

3. Federal, state and local public health agencies at times conflict with recommendations. The pandemic has also been politicized and continues so even after the election.

Once Joe Biden becomes President his main goal will to to make a strong stand for consistency in regulations for Covid19 control.

See How Coronavirus Restrictions Compare to Case Counts in Every State - The New York Times

Mysteries Solved: Telehealth, Data Security and Privacy | Healthcare IT Today

The following is a guest article by Gerry Blass, President and CEO at ComplyAssistant and Donna Grindle, Founder and CEO at Kardon. Even prior to the COVID-19 outbreak

Highlights:

Even prior to the COVID-19 pandemic, the use of telehealth applications and services was on the rise. A January 2020 survey by the American College of Physicians (ACP) showed an increase in usage of telehealth technology for remote care management, patient monitoring, e-consults and video visits. The survey results indicated that video visits saw the largest year-over-year increase in usage, from 3 percent in 2019 to 10 percent in 2020. When asked about barriers to using telehealth technologies, respondents cited their top five:

They were more comfortable examining patients in person and communicating face-to-face.

They had challenges integrating virtual care into an already established workflow.

They did not have the staff to set up and run the technologies.

They were concerned about potential medical errors.

Their patients did not have access to technology to support virtual care.

If we fast-forward from January 2020 to April 2020, we saw that a vast number of physicians went from little or no usage of telehealth, to an astounding increase in the rate of usage. A physician survey from Merritt Hawkins conducted in April 2020 showed that nearly 50 percent of physicians have embraced telehealth, up from only 18 percent in 2018.

The good news is the use of telehealth technologies and services is on the rise. Nearly every type of provider is using telehealth technology. Despite the previous barriers to acceptance, physicians and patients love it. We won’t go back now.

The bad news? The sheer need to act quickly during a crisis, the desire for physician practices to do whatever possible to care for their patients and keep their businesses viable, and the temporary HIPAA waivers by the Office for Civil Rights (OCR) all meant that technologies were often not vetted or implemented properly to comply with HIPAA privacy and security regulations.

If we compare this to Meaningful Use (now known as Promoting Interoperability) and the Affordable Care Act, providers had years to implement usage of electronic health record (EHR) systems. Even with years to plan and implement, data security was not a priority, which is partially why we started to see an uptick in cyberattacks around 2015. With COVID-19, implementation of new telehealth technologies occurred so quickly that proper vetting and security protocols simply fell to the wayside.

In addition, when small practices began to roll out telehealth technologies, they quickly realized that the technologies may not work as well in practice. Performance and quality issues and the inability of providers to use such products as indicated led providers to the path of least resistance—video chat, email and SMS texting—none of which is secure or meet HIPAA regulation standards.

Providers’ top three questions answered

In our daily interactions with providers, we understand very clearly that patient care always comes first. Always. We agree, but also want providers to understand that HIPAA still applies, even during a crisis, and providers still need to maintain security of data and patient privacy.

And, since we are all moving at such a fast pace, there is no single point of real, accurate information. To that end, here are the top three questions from providers regarding the use of telehealth and ensuring data privacy and security.

Has HIPAA gone away?

This is arguably the most common question we receive from providers. The answer is a resounding no! Though the Centers for Medicare & Medicaid Services (CMS) and the Office for Civil Rights (OCR) issued emergency waivers to provide flexibility during the pandemic and to grant payment parity between telehealth and in-person clinical care, the HIPAA Rules still apply.

How does enforcement discretion apply to me?

The Office for Civil Rights (OCR) in March issued a Notification of Enforcement Discretion, which essentially says that covered entities (CEs) will not be subject to penalties for HIPAA breaches related to telehealth during the pandemic, assuming the CE made a good faith effort to protect the data. The OCR will use “enforcement discretion” to determine good faith or negligence. We’ve seen, however, that there are physician practices that intentionally decided to use a non-secure telehealth technology even when they had secure options already available and in use. This leaves them open for OCR to make the determination whether or not they acted in good faith and could be found negligent.

Do patients still have a right to privacy given the circumstances?

Yes, yes and always yes. Patients have not given up their right to privacy because of COVID-19 or any other crisis. Unfortunately, there is a lack of true understanding—even among individuals—of what we can and cannot say. In working with providers, we often hear stories of COVID-19 diagnoses shared with parties who should not be privy to that information. In one example, we learned that a small town’s post office decided not to deliver mail to a particular person due to a rumor that the mail recipient had been diagnosed with COVID-19. Regardless of the time, the diagnosis, crisis or not, patients still have a right to privacy.

A Hidden Advantage Of Telehealth: Patient Access To Specialized Programs

You may have access to multiple providers is availability is an issue. telehealth-based specialty programs are helping to balance and redistribute patient flow in a newly-efficient way. Rather than pitting facilities and providers against one another, these efforts allow patients to access available capacity in a manner that wouldn’t have been possible when virtual care efforts were one-off propositions.

In this case, I found a program whose location I could conceivably visit in a pinch. This seemed to offer social workers, discharge planners and the like a feeling of security, particularly given that they might very well have had face-to-face contact with staffers there before.

That being said, getting patients the specialized care and support they need will be more important than referring them to programs with which they have had long-term contact.

If your provider is unavailable there are a multitude of telehealth providers avaialble such as 

Mysteries Solved: Telehealth, Data Security and Privacy | 

Hospitals scramble to get ready for coronavirus vaccines |

From ultra-cold storage capabilities to extra security staff, facilities are bracing now for their role in distribution of an eventual vaccine.

Hospitals will play a key role once a vaccine receives an emergency use authorization from the FDA, which could happen as soon as next month. They will move quickly to vaccinate their front-line healthcare workers and then their patients and surrounding communities.

But the task, like so much else related to the novel coronavirus, is unprecedented. 

The task is complicated not only by shipping logistics and environmental control, it is also regulated by each state and territory, along with six major metropolitan areas, has its own distribution plan that has to be approved by the Centers for Disease Control and Prevention. Those 64 plans are generally based on what was drawn up for distribution of the H1N1 vaccine more than a decade ago.  To add further complication, the FDA has multiple candidates for an EUA that require different storage and administration tactics.

Much of the planning is already underway, but only so much can be done until an EUA is granted. Two vaccine candidates have so far said they have data showing efficacy at about 95% — one from Pfizer (BioNTech) and the other from ModernaThe crucial raw data, however, have yet to be released for peer review.

With healthcare workers first in line for a vaccine, the process for hospitals will start as soon as a vaccine is approved, and Trump administration officials said this week they expect doses to be at the jurisdictions within 24 hours of approval.

"Hospitals have borne the brunt of this pandemic," said Julie Swann, health systems expert with North Carolina State University. "Hospital staff, the doctors and nurses, have just been overwhelmed in the ERs and the hospital wards. I'm glad they are among the priority groups for this vaccine and I'm hopeful that the vaccine will decrease the workload they have borne for this entire time."

Much of the work involved for vaccination will be at the final mile, from vial to patient.  The distribution process will be along classical distribution channels such as FEDEX, UPS established routes. President Trump has promised the use of DOD assets for distribution of the vaccine. The logistical infrastructure is already in place.  Once the FDA grants the EUA shipment will begin within 24 hours dependent soley upon availability.

The processes are already well underway.

Many potential vaccine candidates will wait until a trial period has been completed from six months to one year in length.  Side effects become more visible after the public release of any new drug or vaccine.

Hospitals scramble to get ready for coronavirus vaccines | Healthcare Dive

What are the Most Significant Determinants of Health

The new category in the medical record, and/or the electronic health record is the Social Determinants of Health (SDOH)  SDOH includes many metrics, which one is the most important.  We can list a number of items on the list. Some of these are familial, genetics, level of education, urban vs rural, insured, uninsured, nicotine usage, size of household, political affiliation, type of employment.

The first part of reading Health Train Express is a quiz that follows. Please take the following quiz.

Pick the one SDOH which has the most influence on your health

1.Genetic

2. Level of Education

3. Urban v. Rural

4. Insurance factor

5. Size of Household

6. Political Affiliation

7. Employment status

8. Zip Code

Click here to register your answers.

Correct Answer

First-of-Its-Kind Med School Makes History- in Oklahoma Cherokee Native Tribal Nation

A wise choice...Sell the Jet Airplane.   Baker sold off the nation's private jet to help pay for healthcare services and allocated $300 million to refurbish rural clinics and create and equip a new state-of-the-art outpatient facility. The Cherokee Nation now operates the largest tribally operated healthcare system in the United States; 27% of its working physicians are tribally affiliated, according to a tribal spokesperson.

First-year medical student Ashton Glover Gatewood, a citizen of the Choctaw Nation, receives her white coat from Natasha Bray, DO, associate dean of academic affairs at the OSU College of Osteopathic Medicine at the Cherokee Nation.

Tribal communities have long lacked resources and medical care. They face crushingly high rates of poverty, substance abuse, and suicide, as well as an increased incidence of chronic health conditions such as heart disease, diabetes, and obesity. The coronavirus pandemic has further highlighted the healthcare disparities that affect these medically underserved people.

Medical educators have struggled for decades — with little success — to boost the number of Native American physicians and to train physicians to staff clinics for chronically underserved rural populations such as the Cherokee Nation. Nationwide, fewer than half of 1% of US physicians are Native American. In the first class at the new school, 22% identify as such.

"After we were removed from tribal lands and there were no teachers, we invested our treasury into teachers," said Bill John Baker, former principal chief of the Cherokee Nation. "This is a natural progression. Just as our ancestors grew their own teachers 150 years ago, we want to grow our own doctors."

"A Match Made in Heaven"

Many credit the creation of the school to Baker's vision. During his tenure as principal chief from 2011–2019, Baker made healthcare a priority for a population struggling with high death rates from cardiovascular disease and lung cancer. Baker sold off the nation's private jet to help pay for healthcare services and allocated $300 million to refurbish rural clinics and create and equip a new state-of-the-art outpatient facility. The Cherokee Nation now operates the largest tribally operated healthcare system in the United States; 27% of its working physicians are tribally affiliated, according to a tribal spokesperson.

The investment in healthcare caught the attention of OSU leaders, who approached the chief with the prospect of opening a medical school on tribal lands. "It was a match made in heaven," Baker said. "We've been investing in our young people for quite some time, sending them to medical school at Harvard and Stanford and all over the country, but when we saw an opportunity to have a medical school right here and not have to ship our kids off, that made perfect sense."

First-of-Its-Kind Med School Makes History

An Outbreak of Covid-19 on an Aircraft Carrier | NEJM

As winter approaches we are told it will be a 'dark' season due to the third wave of COVID19 pandemic Some of us may have forgotten the Outbreak of Covid-19 on the Aircraft Carrier, U.S.S Theodore Roosevelt, CVN 71

Unknowingly and without much warning CVN 71 would become a laboratory to study the epidemiology of a novel Coronavirus,  COVID 19. The naval vessel, with a shipboard complement of approximately 6000 sailors who were mostly young and between the ages of 18 and 35 had been docked in Southeast Asia and set out to sea at the first indication of the Covid19 outbreak in Asia.. Immediately upon leaving port. the crew was tested for coronavirus and found to be negative.  Several days later at sea personnel became ill and were tested again.

BACKGROUND

An outbreak of coronavirus disease 2019 (Covid-19) occurred in the U.S.S. Theodore Roosevelt, a nuclear-powered aircraft carrier with a crew of 4779 personnel.

METHODS

We obtained clinical and demographic data for all crew members, including results of testing by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). All crew members were followed up for a minimum of 10 weeks, regardless of test results or the absence of symptoms.

RESULTS

The crew was predominantly young (mean age, 27 years) and was in general good health, meeting U.S. Navy standards for sea duty. Over the course of the outbreak, 1271 crew members (26.6% of the crew) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by rRT-PCR testing, and more than 1000 infections were identified within 5 weeks after the first laboratory-confirmed infection. An additional 60 crew members had suspected Covid-19 (i.e., the illness that met the Council of State and Territorial Epidemiologists clinical criteria for Covid-19 without a positive test result). Among the crew members with the laboratory-confirmed infection, 76.9% (978 of 1271) had no symptoms at the time that they tested positive and 55.0% had symptoms develop at any time during the clinical course. Among the 1331 crew members with suspected or confirmed Covid-19, 23 (1.7%) were hospitalized, 4 (0.3%) received intensive care, and 1 died. Crew members who worked in confined spaces appeared more likely to become infected.

CONCLUSIONS

SARS-CoV-2 spread quickly among the crew of the U.S.S. Theodore Roosevelt. The transmission was facilitated by close-quarters conditions and by asymptomatic and presymptomatic infected crew members. Nearly half of those who tested positive for the virus never had symptoms.

It is interesting in lieu of the present explosion of reported positive Covid 19 tests of over 100,000 cases/day if these statistics are carried forward today, only 50,000 are symptomatic from COVID 19. The reliability of the nasal swab test method has been called into question. Testing procedures have evolved in the past 9 months to included PCR identification, a rapid test, and also purported to be more accurate.  

                                                         @elonmusk

Currently, Elon Musk stated he had four tests in one day and reported two were positive and two were negative. He did not state if the tests were done at the same facility or whether he was symptomatic.

Authenticity of RT-PCR

Musk's statement calling the tests "bogus" has once again raised concerns about the authenticity of the PCR tests that are key to isolating the COVID-19 positive cases in order to curb the transmission of the disease. However, as per a report by Healthline, experts say the current diagnostic tests for the new coronavirus are highly accurate, but the antibody tests are not as trustworthy. The typical swab tests are 100 percent effective, and while the PCR offers the capacity to detect RNA in minute quantities, whether that RNA represents infectious virus may not be clear, according to scientists. Testing makes the enemy visible, Dr. Emily Volk, an assistant professor of pathology at the University of Texas-Health in San Antonio and president-elect of the College of American Pathologists (CAP) reportedly said. She added that the RT-PCR nasopharyngeal tests should be conducted 8 days after suspected exposure for more accuracy. 

For additional drama the incident created a wave of dismissals and resignations in the U.S. Navy.  The report of the outbreak was transmitted via insecure channels rather than through the routine chain of command. The ship's commander, CAPT, Brett Crozier, pleaded for help from the Navy, sending an e-mail to ten Pacific Fleet admirals and captains, including his superior, the commander of Carrier Strike Group-9, and the commander of the Pacific Fleet, requesting that his ship be evacuated.[50][51][52] Crozier was relieved of command for not reporting through the chain of command.  Amidst this Crozier was then reinstated due to congressional action, and finally relieved of his command but allowed to remain in the Navy. The events rapidly became politicized.

On April 2, 2020, while serving as Acting Secretary of the Navy, Thomas Modly dismissed Captain Crozier from command of the Theodore Roosevelt. Modly said he had lost confidence in Crozier's judgment because he claimed the letter went against the advice of Admiral Michael M. Gilday, Chief of Naval Operations, who argued that usual Navy procedures would require an investigation before such an action.[20]. 

The politicization of the Covid 19 pandemic has caused real harm through real or imagined threats to health and national security

Without question, this has created confusion and a lack of trust toward federal representatives.  Most citizens trust on the recommendations of public health officials.

 NEJM

The web is full of junk health info. This startup wants to change that | ZDNet

A crowdsourcing platform aims to provide better insight into health issues than is currently available..

Digital Health transformation announcements are all over the place.  

Where is it going?

Covid19 fuels, even more, use of health IT, including telehealth.  The use of telehealth (video) expanded over 1000 percent in less than one month when social distancing and lockdowns prevented in-person visits to clinician offices,  Fortunately, the infrastructure was already existent. It was a matter of training providers and patients to utilize the untapped resource.

There remain issues that are worrisome. 

In the age of social media, blogs, and online forums, the most common practice when feeling slightly under the weather has undeniably become to resort to a quick Google search. Unfortunately, when they are not unnecessarily worrying, the answers found on the web are typically inconclusive.

That observation is what prompted Israeli entrepreneur Yael Elish to launch StuffThatWorks, an AI-based online platform that collects crowdsourced data about a host of chronic conditions. The idea is that, unlike Facebook groups or Reddit threads, the information shared by patients is centralized and assessed for quality to readily provide informed data to other users who are enquiring about their own symptoms.

                                            INFORMATION IS POWER

                                             

You know your condition best. How it feels. What aggravates it. Which treatments work. (And which ones don’t.)

Let’s share our experiences in an organized way and discover what can work best for each of us. StuffThatWorks is a crowdsourcing website to gather data for many health conditions. Take the survey to contribute your knowledge of your own condition which will be aggregated using artificial intelligence.

The use of artificial intelligence and crowdsourcing offers a powerful means of collecting health data from patients and aggregating the information for reports using a survey methodology offered by StuffThatWorks

Not only for crowdsourcing, but artificial intelligence also has broad applications in digital health transformation for virtual rounding and others.

The web is full of junk health info. This startup wants to change that | ZDNet

Experts just ranked the best diets, and their choices will probably surprise you | by Popular Science

Who likes to diet?                       That's what I thought

This year’s rankings have a tie for first place between the DASH and Mediterranean diets. You could probably come up with the guidelines for both without doing any Googling because they’re basically just “eat the foods you’re always told to eat.” Focus on fruits, veggies, fish, lean meats, and whole grains. Cut back on sugar and starches. DASH stands for Dietary Approaches to Stop Hypertension because it was originally designed to, you guessed it, lower hypertension. The next four diets — flexitarian, Weight Watchers, MIND, and TLC — are all essentially variations on that theme. MIND stands for Mediterranean-DASH Intervention for Neurodegenerative Delay and does exactly what the name implies, while TLC stands for Therapeutic Lifestyle Changes.

Experts just ranked the best diets, and their choices will probably surprise you | by Popular Science | Popular Science | Medium

Recommendations From the Advisory Committee on Immunization Practices for COVID-19 Vaccination Implementation

WHO Coronavirus Disease (COVID-19) Dashboard

COVID 19 When will it be Ready?

The topic of a COVID 19 is on everyone's mind as well as when and if a vaccine will become available. We hear different stories from President Trump, Anthony Fauci, M.D., and other sources.  It has been reported China, Russia, and other countries already have the vaccine and are beginning the immunization process.

Historically the United States is often one of the last countries to approve drugs and devices for marketing. This has always been the process.  All new drugs, vaccines, and medical devices must pass three clinical trials.  This can take several years or more.  Scientific advances in viral science such as CRISPR, gene splicing, and vaccine manufacturing have reduced the time to market and reduced the risk of serious complications.  Previously viral particles were developed in chicken eggs, denatured (killed) and the resulting antigen injected into humans after trials in animals such as pigs.  Primate testing was eliminated due to ethical concerns years ago.  Today a COVID 19 particle can be reverse-engineered so that it is not necessary to use an entire viral particle.  Only the protein of the viral wall (the spike on the COVID 19 particle needs to be used to produce a vaccine. 

 

This much has already been accomplished by multiple manufacturers and several vaccines are in clinical trials.  During the earlier phases of clinical testing, several early vaccines were disqualified due to serious side effects. 

Numerous estimates for completion and release of a vaccine range from two months to mid-2021. The approval process has been truncated considerably.

There will be significant time needed for distribution and supply chain logistics will be significant.

Not everyone will want to be inoculated.  Even today there are many skeptics about the worth of vaccination.  Different vaccines yield different efficacy.

The length of a clinical trial III can determine if side effects will be recognized prio to release. Time will tell after at least six to 12 months elapse.   The number of trial patients is relatively limited in this study.

Re-Envisioning Clinical Trials During The COVID-19 Pandemic

Solidarity” clinical trial for COVID-19 treatments

Solidarity Therapeutics Trial produces conclusive evidence on the effectiveness of repurposed drugs for COVID-19 in record time.   

There have been conflicting reports about the efficacy of Remdesivir NEJM final report

WHO trial casts doubt on remdesivir's efficacy

Health Train Express makes no recomendation as to the efficacy, safety or use of any pharmaceutical products discussed in this letter.  This is a fluid and dynamic situation for the forseeable future.

Credit and attribution is given to the authors noted in this article.  Continue to distance, wear masking and sanitization .

Scientific and Ethical Principles Underlying Recommendations From the Advisory Committee on Immunization Practices for COVID-19 Vaccination Implementation | Infectious Diseases | JAMA | JAMA Network

Pocket - A “robot” doctor told a patient he was dying. It might not be the last time.

                                        Doctors must use good judgment in using telemedicine tools.

The rapid influx of advanced technology is changing the practice of medicine — at times for the better, but sometimes for the worse. Nowhere is this more apparent than a story where a physician told a fatally ill man in a Fremont, California, hospital that he was dying via video chat on a screen attached to a robot. The news should serve as a wake-up call to the medical establishment on the limits of technology.

The patient, 78-year-old Ernest Quintana, was sitting in his hospital room when a “telepresence robot” — or a mobile robot with a video screen that live-streams a physician in another location — rolled in and informed him that there was nothing that could be done to treat him. Quintana, who had chronic obstructive pulmonary disease, was with his granddaughter and a nurse when he was told his options for managing pain at the end of his life. The granddaughter, shocked at this bombshell dropped from a disembodied robot, filmed part of the encounter, which subsequently went viral online. Mr Quintana died the following day.

Yet a knee-jerk reaction may distract us from looking at the big picture. Just like any medical technology, digital health can be an excellent tool for better, patient-centered care. But it also comes with risks that could erode the practice of medicine, especially for patients who might already have limited access to health care resources and physicians.

The promise of digital technology — when used appropriately — could in fact allow doctors to be more humane. Eric Topol, a cardiologist, and the author argues this persuasively in a just-published book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again. For example, doctors are forced to spend much of their time interacting with patients taking notes. But if advanced transcription services could transcribe and document complex discussions between patients and their caregivers, this could not only open up time for doctors to spend being present with their patients, it could give patients a literal voice in their own medical record. Artificial intelligence could and should successfully offload inane repetitive tasks from physicians and could provide them the time to look their patients in the eye, rather than eyeing the computer screen.

The most critical issue is for digital health to allow providers to give face to face time to their patients where robots or artificial intelligence cannot.

Pocket - A “robot” doctor told a patient he was dying. It might not be the last time.