Quick take: Positive COVID test? Act fast! COVID-19 remains a lethal pandemic. All COVID-19 positive patients should be considered for early treatment, before you get too sick. Highly effective COVID-19 medicines are now widely available. New treatments must be started within the first 5 days, so it is essential to act fast. At least 40% of Massachusetts residents qualify for early at-home treatment. New treatments reduce the risk of serious illness or death by 89%. Detailed information is available at this Massachusetts Department of Public Health website.
Who qualifies to receive early COVID-19 medications?
Adults who have mild-to-moderate COVID-19 and are within five days of symptom onset (7 days for IV medicine), and who are at high risk for serious disease qualify for these highly effective treatments.
Pediatric patients who are at least 12 years old and over 40 pounds qualify for the oral COVID-19 treatments. Infants and children 28 days and older and who weigh at least 7 pounds qualify for intravenous treatment.
Who is at high risk for progression to serious illness or death? Roughly 40% of all Massachusetts residents (more in other states). If you have any of the following conditions, you are at high risk for progression of COVID-19 to serious illness, hospitalization, or death:
Age over 65 years Overweight or obese Diabetic COPD or asthma Diseases of the heart, lung, liver or kidney Pregnant Dementia Cancer Disability Substance use disorder Mental health disorder Immunocompromised The full CDC list is here.
Clinical trials have shown Paxlovid pills reduced the risk of COVID-19 related hospitalization or death by 89% compared to placebo in individuals with mild-to-moderate COVID-19, when given within five days of symptom onset.
Paxlovid pills are currently readily available at many pharmacies including CVS and Walgreens. Urgent care centers and pharmacies with “minute clinic” clinicians can prescribe this medication, often with a telephone or video at-home consultation.
There are currently four COVID-19 treatment options available in Massachusetts today:
2 antiviral pills are available: Paxlovid (must be taken within 5 days of the first COVID-19 symptom) Molnupiravir (must be taken within 5 days of the first COVID-19 symptom)
2 intravenous (IV) treatments are available: Remdesivir, an antiviral medication (must be given within 7 days of the first COVID-19 symptom) Bebtelovimab, a monoclonal antibody treatment that helps your body fight the coronavirus (must be administered within 7 days of the first COVID-19 symptom)
A quick, easy, and free telehealth program for COVID-19 treatment is now also available in Massachusetts:
This program is available to Massachusetts residents 18 years and older who have tested positive for COVID-19, and who are experiencing mild-to-moderate symptoms. If you live in Massachusetts, simply go to this website to obtain a free video telemedicine consultation to determine if you qualify for free treatment. This program is also available in English, Spanish, Haitian Creole, and Portuguese.
For those who do contract COVID-19, whether you are vaccinated or not, if you have even a single risk factor listed above, please talk to your physician or nurse practitioner about taking one of the highly effective medications available, which can dramatically lower your risk of hospitalization and death.
Vaccination: Unvaccinated people are much more likely to be hospitalized and die of COVID-19. Vaccination and staying up to date on COVID-19 boosters continues to be the most effective way to protect yourself against COVID-19.
An infectious disease expert recently told me, “It is not the fault of the unvaccinated that the pandemic continues. However, it is the fault of the unvaccinated when they end up intubated in the hospital ICU.”
How deadly is COVID-19?
COVID-19 was killing 10 times as many people as a bad year of the seasonal flu in 2020 -2021. (COVID-19 has resulted in roughly 500,000 deaths per year in the US in 2020 -2021 rather than 10,000 to 50,000 deaths per year typically seen in the US due to the flu). Today, the Omicron variant of COVID-19 is killing five times as many people as a bad year for the seasonal flu (roughly 500 COVID-19 deaths per day in the US rather than 100 flu deaths per day due to a bad seasonal flu).
You may be through with COVID, but COVID may not be through with you.
The omicron variant of COVID-19 is not milder than the earlier versions of COVID-19. A new Harvard study concludes that fewer people are dying of COVID today due to prior vaccination or partial immunity from prior infection, not because omicron itself is mild. Omicron is deadly. Please contact your healthcare provider urgently if you test positive for COVID-19. Lifesaving treatments are available.
Monoclonal antibody therapy is an important but underused treatment for preventing severe disease and death from COVID-19.
Monoclonal antibody therapy is the best available therapy for people over 12 years of age who test positive for COVID-19 and who have risk factors for severe disease.
It reduces hospitalizations and death by 75% to 85%.
It is provided free of charge to any US resident.
Real fast take: Monoclonal antibody therapy is safe; it’s effective and it saves lives: use it!
Monoclonal Antibody Therapy:
Monoclonal antibody therapy is the most effective treatment to date to prevent patients with mild or moderate cases of COVID-19 from developing severe disease, hospitalization, ICU admission, intubation and death. Monoclonal antibody therapy reduces the number of viruses in the patient and lessens symptom severity. It has been demonstrated to reduce COVID-19 hospitalizations and death by 75% to 85%.
When administered within 10 days of onset of COVID-19 symptoms, this one-time treatment is highly effective in killing the virus, preventing symptoms from worsening, and avoiding hospitalization. When administered early, many patients report a rapid and complete resolution of symptoms.
Please remember, monoclonal antibody therapy is not a substitution for vaccination. Vaccination is still the best first line of defense against COVID-19.
What is monoclonal antibody therapy?
This medication consists of antibodies to the virus, quite similar to the antibodies that your own body makes when you are vaccinated or infected with the virus. However, the therapy gives patients an immediate boost in the number of these antibodies. These antibodies are synthesized in a lab. They do not come from other patients.
The monoclonal antibodies kill the virus early before the virus can multiply and make a patient very sick. These antibodies attack the so-called spike protein on the virus, blocking the virus from attaching to a patient’s cells. This slows the growth of the virus within the patient, while the patient’s own body revs up its own natural immunity systems.
The US Food and Drug Administration (FDA) issued emergency use authorization for monoclonal treatments for COVID-19 patients or exposed people, aged 12 and older, who are at moderate or high risk for developing severe COVID-19 disease. This includes many or most adult COVID-19 patients in the US.
Monoclonal antibody therapy involves administering a small amount of medication intravenously (into your vein) over 20 to 30 minutes, or it can be administered subcutaneously (as injections under your skin). The single treatment is followed by an hour of patient monitoring.
This therapy can be administered in an outpatient medical clinic, an emergency room, a long-term care setting such as a nursing home or even in a patient’s home.
For those who would like a more in-depth discussion of the benefits of monoclonal antibody therapy, here is the link to a one hour webinar, with 5 Massachusetts experts, which I moderated for the Massachusetts Health & Hospital Association’s physician leaders on November 22, 2021.
Which patients are eligible to receive monoclonal antibody therapy?
This medication is available for use in patients who are not yet sick enough to be hospitalized and who are at an increased risk for progression to severe disease, hospitalization, and death and who are at least 12 years old.
This therapy can also be given to high-risk patients (for example, nursing home residents) who have simply been exposed to COVID-19, prior to testing positive for COVID-19. We call this prophylactic therapy.
Who is considered at increased risk for severe COVID-19 disease, and therefore an ideal candidate for early treatment with this life-saving disease as an outpatient?
If you have tested positive for COVID-19 within the past 10 days, please contact your healthcare professional to discuss monoclonal antibody therapy. The sooner, the better.
Are there side effects to monoclonal antibody treatment?
Allergic reactions can happen with the administration of this medication, like any medication. Patients are therefore evaluated for the development of any signs of allergic reaction for one hour after this one-time treatment.
Most experts believe that these antibodies may limit your own body’s ability to develop an immune response during a subsequent COVID-19 vaccination for a brief period of time. Hence currently, it is recommended that patients delay COVID-19 vaccination for 90 days after receiving monoclonal antibody treatment. Other rare side effects can occur. Feel free to discuss this with your healthcare provider.
Do yourself a favor; do your family and friends a favor and do me a favor; if you test positive for COVID-19 and qualify for this life saving treatment, seek it out. The life you save may be your own.
Black Capped Chickadee, Ipswich River Wildlife Sanctuary
As Vice President, Clinical Integration at the Massachusetts Health & Hospital Association, I have organized and moderated weekly and biweekly Zoom COVID-19 meetings with the Chief Medical Officers (the chief doctors) of Massachusetts’ leading hospitals and physician groups throughout the past year. We have hosted some of our nation’s leading genetic, vaccine and infectious disease physicians and scientists, to update us on the evolving science of COVID-19 during these meetings. I personally delivered my first Coronavirus update to this group, over one year ago, on January 29, 2020. That day, there were only 5 known cases of this deadly pandemic in the United States. The disease had not yet even been named, “COVID-19.”
We have learned much since then, some through tragic experience. There is so much factually incorrect information out there, I am writing to share the vaccine facts with you.
In March of 2020, I wrote on DefoSays.com, that experts believed that without the development of a vaccine or successful treatment, the United States would suffer approximately 1 million deaths to this disease. Many were shocked and others could not believe it. Sadly, to date, roughly ½ million Americans have died from COVID-19. The good news is we now have two astonishingly safe and effective vaccines. Today, we can finally stop playing defense and go on the offensive against this awful disease, revive our economy and get our lives back to normal.
I encourage all of you to receive the vaccine when you are eligible. As a practicing physician, I received the vaccine when it was my turn at the hospital where I work, and I didn’t feel a thing.
If we all get vaccinated, not only will we be protecting ourselves, but we will also be protecting our loved ones and our neighbors against COVID-19 and ultimately put an end to this once in 100 years pandemic catastrophe.
Vaccine risk verses risk of COVID-19:
The COVID-19 vaccine is a critical tool to protect yourself and to end the pandemic; but you might have questions about its safety. You should know:
The same safety measures used for all vaccines were followed for the COVID-19 vaccine.
Tens of thousands participated in vaccine trials to prove they are safe.
Since the vaccine trials, tens of millions of people of different races and ethnicities have gotten vaccinated and only experienced mild side effects.
When it’s your turn, trust the facts, get the “vax.”
The serious reaction rate for the two COVID-19 vaccines available in America today is 2.5 people per million patients who received the vaccine. This is similar to the common childhood and adult vaccines we have all routinely received in the US. To put that in perspective, the death rate of COVID-19 in America is at least 10,000 dead people per million patients. COVID-19 is now the number one killer in America.
The serious reaction rate to penicillin is 100 to 500 cases per million, and we don’t think twice about taking penicillin when it will help us.
According to the data from the Centers for Disease Control, (CDC), as of 2/13/2021, 27,229,862 Americans have been proven to have contracted COVID-19 and 473,669 Americans have died from it. Most experts agree this is likely an underestimate of both the number of those infected and those who have died of COVID-19. That means for every 1 million Americans known to be infected, 17,616 have died. While it is true that in the US, a significant minority of patients with COVID-19 are asymptomatic and 80% of patients with COVID-19 symptoms experience only a mild or moderate illness, yet 20% of these people suffer severe disease requiring hospitalization and oxygen therapy.
Is it logical to let the fear of an exceedingly rare serious reaction (2.5 reactions per million, none of which were fatal) keep you from receiving a lifesaving vaccine to prevent a lethal disease? (In the US, contracting COVID-19 results in:200,000 people hospitalized per million, 50,000ICU admissions for respiratory failure, shock and multi-organ dysfunction/failure per million and it continues to kill 17,616 people per million.) Vaccination will also hasten heard immunity, protecting millions of others.
Vaccine Safety:
I can personally reassure you that this vaccine has undergone rigorous testing. It has proven to be a safe and effective vaccine; remarkably so. It is more effective in preventing disease than our annual flu shots.
Both of the US Food and Drug Administration (FDA) authorized vaccines are safe. Prior to FDA authorization, vaccines are required to undergo the highest level of scrutiny regarding safety, of any drug approved. This is because they are administered to otherwise healthy people, and any risk from the vaccine must be far outweighed by the potential benefit of the vaccine.
Both the Moderna and Pfizer vaccines have been held to the highest safety standards of the FDA. The mRNA technology utilized in both vaccines has been utilized in cancer treatment for years.
Mutant COVID-19 strains:
As of this date, the two vaccines authorized for use in the USA are effective against all known mutant strains of COVID-19, although their protection against the South African strain is somewhat reduced, in comparison to the other strains. But as long as the virus is circulating in humans, every single infection affords the virus an opportunity to mutate into a more deadly strain. We must end this terrible pandemic, and vaccination is the only way to do it. The latest information about the new variants can be found by visiting the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant.html
Vaccine side effects:
Just like any other medicine or vaccine, there is a chance that you will experience side effects after vaccination. These tend to be mild, and if you do experience them, they are proof that your body is building immunity. In fact, if you experience side effects to the vaccine, which does not contain the entire virus, just imagine what contracting COVID-19 would have been like.
The common mild side effects of the vaccine include pain at the injection site, fatigue, headache, muscle pain, chills, joint pain, swollen lymph nodes (in the vaccinated arm) nausea, vomiting, and fever. Younger people tend to experience these more commonly than older people, and more often after the second dose. If you are young, it might be prudent to schedule the vaccine the day before you have a day off, in case you have any side effects the next day. These side effects usually only last 24 hours.
Interestingly, just because someone has symptoms after vaccination does not mean the vaccination caused that side effect. People experience fevers, headaches, swollen glands or joint pain etc., all the time, and may experience this around the time of vaccination by random chance. While vaccination site pain will likely be due to the vaccination, the other common mild “side effects” noted above were also experienced by the placebo group in the trials 1/3 of the time, indicating that these common conditions are unrelated to the vaccination.
Pfizer mRNA vaccine
Percent of people with any symptoms: 59% after 1st dose, 70% after 2nd dose
Note: in placebo (no vaccine) group: 47% symptoms after 1st dose, 34% after 2nd
In my opinion, the risk of COVID-19 hospitalization, intubation, death, and post-infectious chronic fatigue, confusion, loss of taste and smell and pain far outweigh the minimal and transient side effects of this safe vaccine.
Vaccine distribution: Health equity has been front and center in the minds of decision makers regarding treatment and prevention during the COVID-19 pandemic. We are first distributing the vaccine to those who need it the most. Priority is being given to those who are the most likely to die if they contract COVID-19, considering medical conditions, age, race, and ethnicity.
As you can see from the CDC data below, Black, Hispanic and Native Americans are roughly twice as likely to die as white Americans, and just like the frail, and elderly; these groups should be and have been prioritized to receive the vaccines first.
Of course, when deciding about any medical treatment, you must look at the benefits, the risk of the alternative and make up your own mind.I only ask that you consider the potential lifesaving benefits of these vaccines for you, your family, and your neighbors when you are offered a chance to receive the COVID-19 vaccine. Vaccination is our only shot at defeating COVID-19 once and for all. I ask you to please join me in making a difference – one person at a time. Thanks.
For more information please visit the following websites:
Some people ask if it is too late to start practicing physical distancing and pandemic hygiene (as detailed in this post).
There is a Buddhist saying which paraphrased advises:
Don’t worry about the past, there is not a thing you can do to change it.
Don’t worry about the future, your feared outcome may never arrive.
Make the most of the present, it is all we ever have.
We owe it to each other to social distance, not for ourselves, but to save the life of someone who we may never meet, a stranger on the street. (And, oh, by the way, it might just save your own life too.)
Flattening the curve not only postpones or eliminates the need to make painful decisions about who can obtain lifesaving care and who cannot, but it will keep our healthcare system up and running for the rest of us who may need a baby delivered, a broken bone repaired or a life saving coronary artery angioplasty during a heart attack.
Do your part to remain physically distant from others and encourage others to do the same. And please ignore the advice that meeting in small groups under some arbitrary number (such as ten) is okay. Until the virus announces it has learned to count and will not infect those in such small groups, we need to completely stop spreading it around.
Please enjoy this poignant link which beautifully underscores the above message.
https://m.youtube.com/watch?v=lr_tEdQvFcc
(If the above link breaks, please search: YouTube Coronavirus Rhapsody. It’s worth it.)
Covid-19 is unequivocally more widespread than you have been told.
The true incidence of Covid-19 in MA, (where I am a local expert) and nationwide is woefully under-reported. This is due to the fact that until a government lab tests a case as positive, it is not reported on the otherwise excellent websites such as Johns Hopkins University’s COVID-19 case counts by country and county.
I have spoken to many MA radiologists who have diagnosed patients with Covid-19 pneumonia, yet the state numbers will not include their patient. These patients’ state laboratory test results are not yet available (as there have not been enough test kits and the lab takes more than 48 hours to turn around results due to high volume).
Experience has taught us that for every hospitalized patient we know about, there are four more in the community who are not reported in the numbers.
Between you and I, one of us is likely to contract Covid-19 within the next 12 months:
While no one knows for sure, it is possible, even probable, based on the evidence to date that most of us will likely contract Covid-19, despite our best efforts. The Prime Minister of Germany, Angela Merkel recently warned that 70% of German citizens might contract Covid-19. Harvard epidemiologist Marc Lipsitch suggested between 40% and 70% of the world’s population will likely contract Covid-19. It is however critical that we delay that eventuality as discussed below.
When we get sick this will be the result:
Based on the experience in Asia and Europe for roughly 80% of us, the symptoms will range from a mild cold to a bad case of the flu, all of which can be treated in the privacy and comfort of our own homes. However, for those of us over 60 years old, and those of us with chronic diseases such as emphysema, diabetes or high blood pressure, we may need hospitalization or even treatment in an intensive care unit (ICU). Covid-19 will kill some of us, most commonly (but not exclusively) those who will die will be older, frailer and sicker patients to begin with.
It has been reported in China that for those patients younger than 30 years of age, the death rate was 0%. The news was worse for older patients. The death rate was reported to be 7.2 percent for patients over 79 years of age. According to that report, slightly less than 1% of all Covid-19 patients with the virus died there. The only good news is that this means over 99% survived.
The math is brutal: If millions of patients required intensive care at the same time, there simply isn’t enough care to go around:
Dr. Anthony Fauci testified before congress that the mortality rate for Covid-19 may be 1%. Hence without drastic measures, Covid-19 may kill 1 million Americans.
For patients with severe Covid-19, hospital care or ICU care can be lifesaving. There are roughly 328 Million residents living in the USA. If only 50% of us contract Covid-19, 164 million patients will fall ill. If 20% of these patients require hospitalization, 32.8 million patients would require a hospital bed. Yet there are less than 1 million hospital beds in America (924,100 hospital bed in the USA). There are only 160,000 ventilators to help patients with pneumonia breath. We have less than 100,000 ICU beds.
You Can Save a Life (Maybe Your Own)
Therefore we must slow the rate of progression of this potentially catastrophic, once in 100 years pandemic:
If the rate of spread of Covid-19 is slow enough, we can “flatten the curve.” 164 million Americans may still contract Covid-19, but if they do so slowly, over time, then there will be enough care to treat the sickest of us, as in the diagram below:
Source: “Flattening the Coronavirus Curve: One chart explains why slowing the spread of the infection is nearly as important as stopping it.”
What your community can do to slow the rage of spread:
Cancel all non-life-saving public meetings: This includes sporting events, classes, religious services, concerts, schools, libraries etc.”
As much as possible, workers should be encouraged to work remotely from home. Face to face meetings should be converted to phone calls, conference calls or webinars.
Business owners, community organizations and government should clean and disinfect frequently touched surfaces more often. They must also provide adequate supplies of hand hygiene supplies at multiple convenient locations.
By limiting the opportunity for the virus to spread, we are flattening the curve.
Reason for optimism:
During the Spanish Flu pandemic of 1918, an estimated 50 million people perished worldwide. That is more than the 40 million deaths due to WW1. However, pioneers of social distancing in 1918 proved we could flatten the curve. In 1918, the mayor of Philadelphia threw a parade to support the war effort. 200,000 people lined the streets to watch. Within three days, every hospital bed in Philadelphia was full of sick and dying flu patients. 4,500 Philadelphia residents died that week alone.
In contrast in St. Louis, a similar sized Midwestern city rigorously began practiced social distancing. Just two days after their first civilian influenza death, the mayor of St. Louis closed all churches, courtrooms, libraries, playgrounds and schools etc. They didn’t throw a parade; they banned all public groups of over 20 people. Their death rate was only half of that of Philadelphia.
Source: “This chart of the 1918 Spanish flu shows why social distancing works”
What you and I can do? Employ social distancing and rigorous hand hygiene:
Practice social distancing now:
· Support school closures and postponement of public meetings
· Telecommute
· Convert in person meeting to calls or webinars
· Cancel family get-togethers, parties, wedding ceremonies (you can still get married, but hold the public ceremony and reception a year from now, once the pandemic is behind us).
· Keep a two week supply of medications, groceries, and household items on hand, in case you are quarantined.
· Check in on neighborhood shut-ins by phone.
· Share your supplies if needed.
Practice pandemic hygiene:
· Don’t go to work (or out) when sick.
· If you need to see a physician, call ahead first.
· Cover coughs and sneezes with your elbow or a tissue, and throw the tissue in the trash.
· Wash hands often with soap and water for at least 20 seconds.
· Avoid touching your eyes, nose, and mouth.
· Get plenty of sleep.
· Exercise.
· Stay hydrated.
· Eat well.
· Don’t shake hands. (Don’t touch their sleeves instead; this is where they have been coughing.)
· A respectful bow while uttering “social distancing” sets a good example.
Be compassionate: Social distancing and a focus on hygiene will help flatten the curve.
The ICU bed you help save may someday be your own.
The
unending string of mass shootings, followed by the increasingly
banal, sterile and hypocritical comments regarding, “thoughts and
prayers,” must cease. The near uniform outrage and grief over mass
shootings and daily urban shootings can be transformed into the basis
for shared responsible action today.
Currently,
the federal Brady
Act mandates that federally licensed
firearm dealers check the background of gun purchasers, to ensure
they are not convicted felons, domestic partner abusers, fugitives or
dangerously mentally ill. However, individuals participating in the
private sale of guns, including those at gun shows, are not required
to conduct such background checks. This is the so called “gun show
loophole.”
The
US public has reached consensus, yet to date, our political leaders
fail to act. Preventable murders (including the shootings of innocent
bystander children) across America have not been mitigated by closing
the gun show loop hole.
Today
unregistered firearm dealers can go to a gun show, purchase unlimited
firearms, then turn around and sell a wheelbarrow full of
Saturday-night specials to convicted criminals without a background
check! Why would anyone support allowing this loophole to persist?
88%
of Americans favor a federal law requiring a universal background
checks for all gun purchases.
72%
of National Rifle Association (NRA) members support this position.
This senseless bloodshed will be curtailed, when we are willing to take courage in both hands, work across the aisle and finally pass a national law requiring universal background checks for all gun purchasers. In a 2015 poll, 83% of Americans favored a federal law requiring universal background checks for all gun purchases. 72% of National Rifle Association (NRA) members support this position. Passing such a bill is not political suicide; it is a path to statesmanship.
In fact, in 2019, the Johns Hopkins Center for Gun Policy and Research confirmed even greater support for universal background checks. Today, 88% of the US public supports universal background checks prior to firearm purchases.
Some
states have a closed the gun show loophole on their own. These states
are 30%
less likely to export guns to criminals in
other states for use in a crime.
We
must not allow anyone to use the second amendment or firearm violence
as a political wedge issue to divide us. Regardless of what we are
told by the talking heads on the competing cable news networks, our
shared human experiences are similar. Our core values are nearly all
the same. What binds us together as fellow human beings is far
greater than our differences. Who does not weep at the loss of a
loved one? Who doesn’t feel the need to protect an innocent child?
Together we are all pilgrims on the same journey.
There is no gap
separating gun owners from non-gun owners in their support for
closing the gun show loophole. Data
proves it. Our political leaders, on all
sides of the political spectrum can and should support their
constituents. Close the gun show loop hole now, once and for all.
While the causes of physician burnout (and clinician burnout more generally) are multifactorial, inefficient electronic medical records (EHRs) and their associated disrupted workflows consistently top the list of the main drivers of physician burnout. Atul Gawande wrote an eloquent piece on the subject entitled, Why doctors Hate Their Computers, in which Dr. Gawande notes “I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me.”
There are EHR optimization pearls your organization can take.
But there are practical EHR optimization pearls any organization can take to reduce administrivia driven burnout. Last week, I co-authored a paper for the Joint Massachusetts Medical Society (MMS) – Massachusetts Health & Hospital Association (MHA) Task Force on Physician Burnout in partnership with the Reliant Medical Group: Changing the EHR from a Liability to an Asset to Reduce Physician Burnout.
This paper includes more than a dozen electronic health record (EHR) optimization techniques organizations can take today to improve the usability of the EHR as well as its associated workflows, in order to reduce unnecessary administrative burden for physicians and other clinicians.
Our message is that there are many interventions compassionate leaders can take today to help mitigate the drivers of clinician burnout. We would be happy to hear what has worked for you.
Each year, the graduating classes of three average size medical schools don’t add a single physician to the US workforce; they simply replace the 300 to 400 physicians the American Foundation for Suicide Prevention estimates kill themselves each year. We lose a doctor a day to suicide.
In a recent blog
post a healthcare CEO asked, “Is the rate of physician suicide
statistically different from that of other highly paid
professionals?” Yes.
The American
Psychiatric Association reported that physicians have the highest
suicide rate of any profession at their annual
meeting in 2018, higher in fact than active duty military personnel.
The time to prevent
physician suicide, rigorously document its occurrence, remove the
stigma of seeking mental health care and to care for suicide victims’
workplace survivors is long overdue.
Physicians know how
to stay healthy. This is why it is especially tragic that the only
cause of death where the risk to physicians is higher than the
general public is suicide.
Worse, we’ve
been aware of this slow motion tragedy for generations and it is
largely preventable. S. Dana Hubbard, M. D., Director, Bureau of
Public Health Education, New York City Department of Health published
the fact that physicians lead the list of suicides by professions in
the American Journal of Public Health, in 1922.
Almost a century
later mystery still shrouds the exact number of physician suicides
each year as families and employers alike are reluctant to tell the
truth in public, due to the fear of stigma. Medical examiners may
have difficulty distinguishing intentional from unintentional
traumatic deaths. Even when a suicide is accurately determined, there
is no consistent reporting of the victim’s occupation.
Most experts agree the physician suicide rate is roughly twice that of the US population in general, and it is even worse for female physicians. A meta-analysis of physician suicide published in the American Journal of psychiatry demonstrated that both male and females physicians are more likely to die by suicide compared to the general population (1.41 times more likely for male physicians and 2.27 times more likely for female physicians).
The
US healthcare system is killing physicians.
Students and young Physicians have been documented to be actually more resilient and less depressed than the US average. Then we are subjected to stress, moral distress and trained to ignore the symptoms of depression until it is too late. A study published in the Archives of General Psychiatry demonstrated that the rate of depression among physicians immediately prior to entering internship was 3.9%. During internship, this rate skyrocketed to 25.7%.
Factors contributing
to the epidemic of physician suicide include:
Repetitive
exposure to death and dying
Exact knowledge
of (and ready access to) lethal means
Stigma
associated with asking for mental healthcare and
Our
profession’s excessive dependence on self-reliance.
While the first two
factors above are likely inherent to the profession, the latter
two factors driving suicide are amenable to mitigation.
Here are Ten Suggestions for 2019:
Put an end to the silent curriculum (“Don’t ask for help. Never show weakness.”) in physician training programs.
Part of the reason
physicians don’t ask for help is that in training we were taught
the unwritten rule: “Don’t ask for help and never show
weakness.”
On my first day of surgical internship, I was naturally a bit apprehensive, given the enormous privilege and responsibility I was about to be given, caring for, and operating on some of the most ill patients in one of the finest academic medical centers in the US. I was shocked and taken aback by the advice the entire group of us surgical interns were given by the senior attending surgeon, tasked with orienting us. He said, “Always remember that while you are here… you are swimming with sharks. So don’t make waves, and if you are bit, don’t bleed.” It is this kind of abusive attitude which I am confident cost one of my female classmates her life, during her surgical residency when she killed herself halfway across the country in another surgical training program.
We must incorporate wellness into both the written (and silent) curriculum.
2. The Physicians need better access to mental health care without fear of punishment for admitting they need help.
Dr. Michell
Hardison, a well-respected family doctor in Raleigh NC chose suicide
over psychiatric care for his depression. His daughter
Anna Hardison Severn revealed, “He was 100% positive that if he
came forward and said he needed help that there would be a reprisal
of some kind.”
State medical boards
are responsible for licensing physicians and protecting the public by
ensuring physicians meet high standards. There is nothing wrong with
medical boards asking physicians if they have a medical or
psychiatric condition which might lower the quality of the care they
deliver. They should not however ask if a physician has ever been
under the care of a mental health professional. For if they do
this, physicians will forgo needed care which could harm the doctor
and jeopardize the quality of the care for their patients.
The Federation of State Medical Boards (FSMB) Workgroup on Physician Wellness and Burnout made 35 recommendations to better address physician burnout. These recommendations should be adopted by all states. They advise against asking probing personal questions regarding a physician’s mental health. The FSMB specifically recommended that state medical boards indicate“it is not only normal but anticipated and acceptable for a physician to feel overwhelmed from time to time and to seek help when appropriate.”
3. Not only should the electronic medical record must be optimized, but processes and systems must be optimized in order to get the most out of this technology and improve user satisfaction.
How it is that
healthcare is the only industry where digitization/computerization
has decreased worker productivity? The epidemic of physician
burnout, driven by administrative hassles, loss of professional
autonomy and increasing workloads is contributing to physician
burnout, depression and suicide.
It is inexcusable
that for every hour physicians spend facing a patient in their
office, they
are forced to spend two hours tending to desk work and
documentation in the electronic medical record.
At UC Davis Medical Health, Scott MacDonald, MD, FACEP demonstrated that by optimizing their electronic medical record’s use, the health system could both dramatically increase physician satisfaction with their EHR and improve their quality of life. They were able to eliminate over 25 hours of unproductive, unnecessary busy work from their physicians’ schedule each month! Imagine how much more time physicians could spend meaningfully caring for their patients and achieving work life balance if this innovation were to be adopted nationwide.
4. Stop the stigma. Employers of physicians, including hospitals, physician groups and residencies must encourage and normalize accessing mental health care.
We must destigmatize and treat physician depression in order to prevent suicide. One study found that access to residency positions was limited for fully qualified students who had requested psychiatric counseling! Only when seeking out a councilor is considered “normal” will physicians ask for help when they need it. All too often, physicians are encouraged to keep vulnerabilities hidden and not ask for help.
5. The practice of requiring medical students and residents to obtain mental health care at their own institution limits confidentiality and should be eliminated.
Until the stigma of obtaining mental health is completely relegated to the ash-bin of history, the confidentiality of accessing such services is critical, particularly for physicians in training. Some student and resident health plans require trainees to obtain healthcare at their own institution, limiting confidentiality for both physical and psychiatric conditions. This paternalistic and antiquated requirement should be eliminated.
6. Peer support should be available at times of great vulnerability:
Medical errors,
patient injuries and patient deaths are obviously painful for the
patient’s families. Less well understood is the fact that
physicians also suffer emotionally in such circumstances,
particularly if they believe they have somehow failed their patient
and begin to second-guess their own competence.
In times of great stress, such as these or when facing a medical malpractice lawsuit, physicians are extra vulnerable to depression and suicide. It is at these times that confidential peer support, advice from a colleague who has endured the same stressor is most helpful. Employers should plan ahead for such events and offer well-structured and readily available confidential peer to peer support programs to their employed and affiliated physicians.
7. We must accurately keep track of suicide rates by profession. State medical examiners should record the occupation of all suicide victims, including what school they are attending if they are in college or graduate school.
Only then can we
identify opportunities for improvement and evaluate whether our
interventions are effective in stemming the tide of this horrific
slow motion tragedy.
This would capture both the number of physicians / medical students who are committing suicide, and also spotlight any outlier institutions.
8. Postvention: Care for the bystanders after a physician suicide is essential.
Post-suicide counseling and peer support is especially important after a colleague has committed suicide. Toolkits such as the American Foundation for Suicide Prevention’s toolkits are available on line. There is even a toolkit specifically designed for medical schools to utilize after a medical student suicide.
9. Encourage all physicians to select their own trusted primary care physician (and regularly check in with that physician).
All too often physicians follow the dictum, “physician heal thyself.” Employers and affiliated institutions should encourage all medical students, residents and practicing physicians to choose their own trusted primary care physician. In addition to obtaining objective evidence based care from a personal physician, these trusted doctors represent another touch point from which distressed physicians can obtain emotional support.
10. Accessing medical care, whether physical or psychiatric, should be modeled by mentor physicians.
Organizational
leaders should model self-care, access mental health care publicly
and publicly reinforce the necessity of a healthy work-life balance.
Together we can
end the epidemic of physician suicide. Let’s make it happen in
2019.
