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.

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