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Changing Minds About Why Doctors Change Their Minds

After Covid, being open with patients about uncertainty may be the surest way to build trust in medicine.

IN 2001, when the pediatric allergist Gideon Lack asked a group of some 80 parents in Tel Aviv if their kids were allergic to peanuts, only two or three hands went up. Lack was puzzled. Back home in the UK, peanut allergy had fast become one of the most common allergies among children. When he compared the peanut allergy rates among Israeli children with the rate among Jewish children in the UK, the UK rate was 10 times higher. Was there something in the Israeli environment—a healthier diet, more time in the sun—preventing peanut allergies from developing?

He later realized that many Israeli kids started eating Bamba, a peanut-based snack cookie, as soon as they could handle solid foods. Could early peanut exposure explain it? The idea had never occurred to anyone because it seemed so obviously wrong. For years, pediatricians in the UK, Canada, Australia, and the United States had been telling parents to avoid giving children peanuts until after they’d turned 1, because they thought early exposure could increase the risk of developing an allergy. The American Academy of Pediatrics even included this advice in its infant feeding guidelines.

Lack and his colleagues began planning a randomized clinical trial that would take until 2015 to complete. In the study, published in The New England Journal of Medicine, some children were given peanut protein early in infancy while others waited until after the first year. Children in the first group had an 81 percent lower risk of peanut allergy by age 5. All the past guidelines, developed by expert committees, may have inadvertently contributed to a slow increase in peanut allergies.

As a doctor, I found the results unsettling. Before the findings were released, I had counseled a new parent that her baby girl should avoid allergenic foods such as peanut protein. Looking back, I couldn’t help but feel a twinge of guilt. What if she now had a peanut allergy?

The fact that medical knowledge is always shifting is a challenge for doctors and patients. It can seem as though medical knowledge comes with a disclaimer: “True … for now.”

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MEDICAL SCHOOL PROFESSORS sometimes joke that half of what students learn will be outdated by the time they graduate. That half often applies to clinical practice guidelines (CPGs), and it has real-life consequences.

A CPG, usually drawn up by expert committees from specialized organizations, exists for almost any ailment with which a patient can be diagnosed. While the guidelines aren’t rules, they are widely referred to and can be cited in medical malpractice cases.

When medical knowledge shifts, guidelines shift. Hormone replacement therapy, for example, used to be the gold-standard treatment for menopausal women struggling with symptoms such as hot flashes and mood changes. Then, in 2013, a trial by the Women’s Health Initiative demonstrated that the therapy may have been riskier than previously thought, and many guidelines were revised.

Also, for many years, women over 40 were urged to get annual mammograms—until new data in 2009 showed that early, routine screenings were resulting in unnecessary biopsies without reducing breast cancer mortality. Regular mammograms are now suggested mainly for women over 50, every other year.

Medical reversals usually happen slowly, after multiple studies shift old recommendations. Covid-19 has accelerated them, and made them both more visible and more unsettling. Early on, even some medical professionals presented the coronavirus as no more severe than the flu, before its true severity was widely described. For a time, people were told not to bother with masks, but then they were advised to try double-masking. Some countries are extending the intervals between the first and second vaccine doses. Of course the state of the pandemic, and of our knowledge about it, has been shifting constantly. Still, throughout the past year and a half, we’ve all experienced medical whiplash.

It’s too early to say how these reversals will affect the way patients perceive the medical profession. On the one hand, seeing debate among medical experts conducted openly could give people a heightened understanding of how medical knowledge evolves. It could also inculcate a lasting skepticism. In 2018, researchers analyzed 50 years’ worth of polling data on trust in medicine. In 1966, 73 percent of Americans reported having confidence in “the leaders of the medical profession.” By 2012 that number had dropped to 34 percent—in part, the authors surmised, because of the continued lack of a universal health care system.

 

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THE ANCIENT GREEK sea god Proteus was able to see the future, but he was forbidden from sharing his prophecies unless he was captured. This was challenging, because he was a shape-shifter: He could become a young man, a tree, a bull, a flame. No one has explored the protean nature of science more prominently than the Viennese scientist and philosopher Thomas Kuhn. In The Structure of Scientific Revolutions, published in the early 1960s, he proposed that science shape-shifts, or advances, through five sequential phases.

The first involves accepting “normal science,” the prevailing theory or “paradigm,” and conducting experiments that merely verify and reinforce the paradigm. During this phase, skepticism is often suppressed. Phase 2 involves finding an “anomaly” that doesn’t fit with the paradigm, but treating it as an outlier. In phase 3, a critical mass of threatening “anomalies” lead to a “crisis”—which prompts phase 4: “revolution,” by way of a series of new experiments to test alternative theories. Finally, a new worldview emerges, a “mature science.” The phases then repeat.

Remarkably, Kuhn didn’t argue that science is in search of “truth,” but rather that it “moves away from” an outdated, problematic, and “primitive” worldview. Also key is that what scientists and non-scientists understand in the new paradigm is reflective of what they see, as well as what they have been taught to see from experience. A switch in gestalt may be “I used to see a planet, but now I see a satellite”—referring to points in time and assuming that the initial observation may have been true. A paradigm shift, on the other hand, may word it as “I used to see a planet, but I was wrong, as it’s actually a satellite.”

Kuhn based his phases primarily on physics. What happens when we apply them to medicine and health care? When we deal with human lives and preventing illness, “advancement” can look a lot like “flip-flopping.” Is a changed recommendation an admission of harm? And where does that leave us with large public health efforts? Medical reversals place doctors in a bind. Improved medical knowledge represents progress, but honestly admitting to a past error may lead patients to see them as incompetent, breeding mistrust.

 

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What if we got rid of reversals? That’s what University of Chicago Medical School professor Adam Cifu and oncologist Vinayak Prasad propose in Ending Medical Reversal: Improving Outcomes, Saving Lives. In many cases, they conclude, recommendations are simply issued too soon and are based on low-quality trials. Guideline committees may succumb to groupthink or feel pressured to reach a consensus where none exists. “If we look at something like peanut restriction,” Cifu told me, “the initial recommendations were mostly based on theory—good immunology theory, but theory nonetheless.” If doctors “stick with what’s evidence-based, our advice will be less likely to be overturned.”

Yet diseases don’t wait for evidence. Doctors must sometimes make medical decisions even if good data is rare or unavailable. Cifu and Prasad draw a sharp distinction between evidence- and theory-based recommendations, but in practice, doctors often adopt a looser framework. They may use lower-quality (often theory-based) recommendations until they can be replaced with higher-quality ones. Doctors combine this knowledge with their own personal experience in making clinical decisions.

Medical guidelines are similarly a composite thing, often seeking to balance new evidence with deference to established authority. And decisionmakers may also consider how a revision will affect trust in the system as a whole. In the 1990s, for example, the rotavirus gastroenteritis infection killed more than 130,000 children globally each year. In 1998 the pharmaceutical company Wyeth released a vaccine, called RotaShield, that dramatically reduced the mortality rate. Within a year, however, doctors and patients poured in with complaints. Among the inoculated, there seemed to be a small increase in a bowel condition called intussusception, which in rare cases can be deadly. In 1999, after 15 reported cases of vaccine-related intussusception, both the Vaccine Adverse Event Reporting System (VAERS) and the Centers for Disease Control ordered that RotaShield be withdrawn from the American market. It’s worth noting that VAERS is limited by the honor code: Adverse events are not confirmed.

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In a 2012 paper titled “The First Rotavirus Vaccine and the Politics of Acceptable Risk,” Jason Schwartz, then a fellow at the University of Pennsylvania, explored the thinking behind the withdrawal. In his view, the decision wasn’t purely evidence-based. Schwartz told me that while some “argued that keeping the vaccine would have, in absolute terms, saved more lives,” the decisionmakers weighed trust: “You can’t have a vaccine out there with a notable risk of a harmful condition.”

According to this reasoning, the RotaShield reversal should increase our trust in vaccines: It shows that the system we use to monitor them works. (Two safer rotavirus vaccines have since been introduced and remain in use.) Vaccines such as MMR have been monitored for decades by the same system, and observers have seen no alarming signs—proof of their extraordinary safety. We’ve recently seen similar safety processes play out with the AstraZeneca and Johnson & Johnson Covid-19 vaccines. Still, a paradox of medicine is that the steps we take to make the system more trustworthy can make it seem less so.

THE FLIP SIDE of that paradox is that getting doctors to be comfortable expressing uncertainty may be the surest way to instill patient trust. Steven Hatch, a professor of infectious diseases at the University of Massachusetts, argues that medical reversals unsettle us because both medical professionals and patients are too fixated on being sure. “The public often thinks that they go to their doctor, the doctor runs the test, and the test reveals the truth,” Hatch told me. “But most of the time, we weigh sets of data and arrive at weighted possibilities which are not rock-solid.”

Doctors might approach different kinds of patients differently. Some people are comfortable with uncertainty and risk; others, says Hatch, struggle “to deal with ambiguity in their lives in general.” With the latter, doctors must resist the temptation to create a false sense of certainty, because “it’s really when things go wrong that a patient may feel cheated by the system.”

Hatch’s observations made me think of Diane, a woman I met a few years ago at a yoga retreat. Now in her sixties and retired, Diane is healthy, active, and cheerful, but she’d gone decades without visiting a doctor. She’d avoided preventative screenings of all kinds, in large part because it seemed to her that medical advice is always changing.

A few years ago, one of Diane’s friends—a woman who’d also avoided routine screenings—died of colon cancer. This inspired Diane to make a few doctor’s appointments and, in December 2019, she had her first physical exam since the early 1990s. Still, she found herself confused about how much uncertainty was normal in the doctor-patient relationship. She told me that when she asked her doctor if a prescribed skin cream would make her skin sensitive to the sun, her doctor told Diane that sun sensitivity wasn’t a side effect. Later, at home, Diane looked up the medication and found a warning that the cream actually did make people more sensitive to sunlight. “The doctor admitted to being unsure, which didn’t bother me,” Diane said. “But then she ended up telling me the wrong information. It’s hard for me to overlook that.”

Diane has struggled with the changing recommendations during the pandemic, and with figuring out how they should shape her behavior. “It almost seems like no one knew what they were talking about,” she recently told me. “First, it was no mask, then it was mask. Now, it’s two masks. It’s hard to keep up.”

Diane’s husband is a pilot, so I suggested a flying analogy. Sometimes a pilot who has been flying the same route for years has to shift because of severe turbulence or weather, perhaps flying thousands of feet higher or lower than what was originally planned. Usually the pilot announces the change to the cabin, and the passengers understand. Most don’t see the pilot as newly untrustworthy or incompetent; on the contrary, they’d worry if the plane shifted course and no announcement was made. Changes are inevitable when new information arrives, and transparency should increase trust, not erode it.

 

The Re-Emergence Effect

It will take time and patience to reemerge from the collective crisis of the pandemic with our mental and physical health intact.

When I met Darren Sudman six years ago, at an event in Palm Springs, I didn’t expect that his story would be one that I would return to time and again as I began examining what makes us thrive and heal after difficult times.

Sudman introduced himself as a former lawyer and a founder of a nonprofit. In 2004, Sudman and his wife, Phyllis, experienced every parent’s worst nightmare: Their three-month-old son, Simon, was found motionless in his crib. He had passed away from sudden infant death syndrome (SIDS), later deemed to be secondary to a heart rhythm disturbance called “long QT syndrome.”

Sudman’s nonprofit, Simon’s Heart, was created with the purpose of screening children early in life. It has kept us in touch over the years. But it was what Sudman shared about how he emerged from this unspeakable tragedy, and was able to move forward, that has continued to stay with me — particularly during this time as I reflect on our collective reemergence after the pandemic.

“My daughter was two and she needed me to get out of bed every day. She was really young and didn’t have a grasp of what was going on, and I had to take care of her. That forced me to wake up and live every day as best I could — she was my motivation,” Sudman told me. He also shared advice his co-worker provided at the time: “‘When you feel grief, let it pull you under and don’t resist it — it’s temporary and when you’re ready, you’ll come back up.’ This idea continues to work for me.”

In March 2021, a survey from the American Psychological Association found that 49% of adults reported feeling uncomfortable about returning to in-person interactions when the pandemic ends, and this included those who were vaccinated.

In China, after lockdowns lifted and people reemerged, over 10% met diagnostic criteria for post-traumatic stress disorder (PTSD). Indeed, for roughly 14 months most of us adjusted to a modified sense of “normal,” in much the same way a person living in a cave for a year may adjust to the lack of cognitive and light stimulation.

Change — even if it comes in the form of freedom — is still uncomfortable. So, it’s no surprise that some doctors are admitting to their own reemergence anxiety, that this summer terrifies a lot of people (perhaps especially introverts), and that many are worried about returning to work. Things will get better and the pandemic as it stands will end and Covid is most likely transforming into an endemic seasonal virus, yet all signs are clear that we must prepare for a reemergence effect.

Javeed Sukhera, chief of psychiatry at Hartford Hospital in Connecticut, shared that the reemergence process may feel similar to grief. “Especially for those who struggle with tolerance for ambiguity and when circumstances are not in their control,” Sukhera shared, “They will either adapt to the stressor and reflect more on the meaning of things, or risk of falling back into maladaptive ways of coping.”

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Reemergence effects are not new.

We can look at butterflies as an example from nature — a caterpillar spends up to two weeks in a cocoon dissolving into a stew of cells, which it then partially ingests before swiftly emerging as one of our most prized insects.

I think back to a training in humanitarian emergencies I took at Harvard several years ago. The crisis situations were almost always in developing countries, where we needed to sort out food, water, and safety (for instance, from civil war and infectious diseases). A core part of our training was how to reemerge from the crisis with our mental and physical health intact. This involved time and connecting to resources to integrate back into the societies we had left — lessons I took to heart and applied during research or clinical work in low resource settings.

There are also examples from history.

Some Holocaust survivors, once freed from Auschwitz, marched across the camp and to freedom, but promptly returned: Writer and psychologist Edith Eger suggested, “They didn’t know what to do with their freedom,” and a return to life was challenging.

We see this in medicine as well.

compelling case of a man who spent decades legally blind had his eyesight restored only to suffer a psychological breakdown as he reemerged with the vision he had become accustomed to not having. The criminal justice system is also illustrative: The recent release of Joe Ligon, who spent 68 years of his life incarcerated, suggests that his true sense of freedom may be linked to how well he is supported during his reintegration into society. Indeed, once we start looking, we see “reemergence effects” everywhere — moments when, after spending a length of time in one state and having adjusted, we are forced to shift to another. Even if our new state is objectively better, our minds are still impacted.

Rachel Yehuda, a professor of psychiatry at Mount Sinai who specializes in trauma, expected many would seek therapy during Covid, the numbers were not as high as expected, which suggests to her that there may be an immense need after the crisis as part of our reemergence.

Joy Harden Bradford, an Atlanta-based clinical psychologist, agrees. “Many people may experience a post-traumatic stress response several months after we emerge that may take them by surprise as they may be getting through this difficult time by not fully acknowledging and processing what’s been happening, likely because it was their only way to keep functioning,” Bradford said.

As such, part of planning for our reemergence will involve anticipating our future mental health needs. Reconstruction after a humanitarian crisis is common, and often provides an opportunity for mental health reform; this was echoed in a UN report published last year. The idea of “building back better” for children’s mental health is instructive and could apply more widely.

“If I had a magic wand, in terms of building unlimited capacity for healing, I would initiate a campaign called ‘Let’s Talk About it,’ meaning, talk about the challenges, and the pain, and how we felt at the time. And it wouldn’t necessarily have to be with a mental health provider,” Yehuda told me. “Ideally, we would come together with people we know in our communities, in places of worship, the gym, yoga studio, or book club and ask each other, ‘What was it like for you?’”

And we may very well emerge better in some ways, perhaps a bit surprised by our own resilience, a point Yehuda wants to underscore.

“Time does heal, and the desire to flex our resilience muscles is powerful. That most of us will recover is an important public health message,” she shared.

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With butterflies, it turns out that my understanding of their reemergence was incorrect. There’s more to the process. When a butterfly emerges from the cocoon it’s still a goopy wet mess. Its wings are too small to fly. To expand them, it must actively pump in fluid from its abdomen — a bit like blowing up a balloon. Then its wings must dry under the sun. And then — as anyone who has spent a prolonged length of time in a hospital bed, and experienced muscular deconditioning, knows well — the butterfly must exercise its fragile wing muscles enough to ensure they stay up against gravity in order to fly.

In other words, a butterfly’s reemergence isn’t swift at all: it takes intention, time, and effort.

Our collective reemergence may be similar. It must be handled with care, patience, and ideally capacity to receive our mental health needs on the other side of this pandemic. Engaging in a collective reenvisioning both around what capacities should be built now, in preparation for that reemergence is part of our collective post-traumatic growth, and goes beyond resilience to involve creating of meaning from crises, which could perhaps buffer some of the harmful elements of the reemergence effect.

Though I didn’t appreciate it six years ago, this was perhaps the biggest lesson I learned from Darren Sudman, which I hope we can all put into practice today as we reemerge stronger and more whole. Sudman’s intentional efforts to steer his family’s crisis into one that could help other parents helped offset his personal horror of reemerging as a parent who had lost a child.

“We had just suffered one of the worst tragedies but through it we [created] new narratives that involve helping prevent this from happening to other children, meeting families with similar experiences. When Jaden, our third child, came home, he brought another ray of sunshine to our house and reinforced the fact that life goes on and there’s still goodness.”

**Originally published in Elemental in May 2021**

Can Prayer Heal?

Does spirituality play a role in health outcomes?

Credit: RawPixel

On the last day of January, my Twitter feed lit up with a curious and heartfelt call: “Please. Please. Please. Everyone PRAY for my daughter Molly. She has been in an accident and suffered a brain trauma. She’s unconscious in the ICU. Please RT and PRAY.”

The tweet came from a woman named Kaye, a lawyer and mother of three in Los Angeles. Her daughter Molly was in a pediatric intensive care unit after suffering a brain injury. I, along with thousands of others, heeded her call, sharing a private prayer that Molly would recover. Soon Kaye began tweeting live as to Molly’s status — she regressed with brain swelling, needing surgical intervention. She was then stable for another day before her blood pressure and the pressure in her brain (intracranial pressure) fluctuated, needing another brain scan and another surgery to reduce the intracranial pressure.

By sharing what was happening for Molly, Kaye brought thousands of us into that small ICU room over several days, highlighting the hard work and efforts by Molly’s doctors and requesting that followers (the number amassed to more than 60,000 within the span of just a few days) do one thing: pray.

The research on intercessory prayer—the formal name for praying to a higher being or force, for ourselves or for others—paints a conflicting picture. In 2020, a published case report caught my eye: A patient’s blindness “resolved” after the patient received intercessory prayer. But the case happened in 1972; surely the details may have become muddled in the retelling over several decades. The same researchers reported on other cases, like prayer for gastroparesis (when the stomach becomes unable to function) in a 16-year-old. Other research suggests prayer may be helpful as an adjunct for pain management among patients who might describe themselves as religious.

In 2006, researchers from the Mind-Body Medical Institute at Harvard Medical School reported on the Study of the Therapeutic Effects of Intercessory Prayer (STEP). This trial involved cardiac bypass patients across six hospitals in the United States. Each participant was in one of three groups: One-third received prayer from others after not being told if they would or not, another third didn’t receive prayer after being told they may or may not receive it, and the last third were told they would receive prayer. In the end there was no significant difference in death rates (mortality) between the groups.

Perhaps most prominently, a Cochrane review from 2009 that reviewed 10 studies and more than 7,500 participants compared intercessory prayer plus standard care with standard care alone and found that the results were equivocal — in other words, prayer didn’t make a difference to the patient’s outcome. That review was then criticized as failing to “live up to the high standards required of Cochrane reviews,” and other researchers have criticized the study more generally.

Yet, spirituality may effectively be a way to create meaning out of the experience. It can also help patients create meaning from their experiences.

Jonah Geffen, a 44-year-old rabbi in Manhattan, echoed some of these same sentiments. His path into spiritual work involved a stint at law school, after earning a master’s in conflict analysis and resolution. Now he works primarily in the community but on occasion gets called into hospitals or people’s homes specifically for healing purposes.

“[As a] rabbi… generally, no matter where you are, what you’re doing, there’s always an element of care involved in it… very often someone looking to heal something,” Geffen told me.

Over the years, Geffen has become prepared to run to someone’s side in the hospital or at home when crisis hits. He adds that the biggest challenge he sees, among those who are chaplains in hospitals, is that much of the time they might be asked to pray for someone outside their faith.

“It’s a challenge with some of the rabbis I know who might be asked to pray for someone. In our tradition, prayers are quite scripted, so the challenge is for them to step out of that and find another way to connect with that person and to God,” he says.

Christina Puchalski, MD, a physician based in Washington, D.C., became interested in spirituality at an early age. “There wasn’t one specific thing that got me interested in orienting myself towards the spiritual needs of my patients. I suppose it was years of knowing my connection to the sacred and that so much of the suffering we see in our patients is of the spiritual kind,” Puchalski told me.

In 1996, Puchalski developed the FICA (faith/belief/meaning; importance/influence; community; address/action of care) spiritual assessment tool for health professionals to help them integrate spiritual views into a patient’s clinical history. Puchalski has worked with everyone from the Vatican to the World Health Organization (WHO). With the WHO, she has advocated to include “spirit” within the definition of health, specifically in the realm of palliative care.

Currently, Puchalski leads the George Washington Institute for Spirituality and Health, dubbed GWish. Established in 2001, the institute has the primary role of raising awareness about the spiritual aspect of patient well-being. It’s the biggest center of its kind in the United States.

In her book Making Health Care Whole, Puchalski defines spirituality as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” She goes on to emphasize that spirituality helps us find meaning and purpose “even in the midst of failed jobs, relationships, accomplishments, and unattained successes, especially at the end of life… The inability to find meaning and purpose can lead to depression and anxiety.”

According to Puchalski, the triggers for potential spiritual growth can include serious illness, aging, loss of a loved one, stress, life change, social events, and tragedies.

So perhaps what Geffen and Puchalski are both alluding to is that asking whether prayer “works”—as in whether it hastens recovery—is not the right question, even if it’s important from a research and evidence-based point of view. Instead, perhaps it’s important to define the outcome more holistically: as a measure of healing for both the patient and their family, one that transcends merely “curing” or “recovery.” As well, perhaps the word “prayer” is unnecessarily constraining. We could instead reframe it as “compassionate and caring presence” for another person, where we genuinely hold their well-being in our thoughts.

On February 15, Kaye shared an update that Molly had passed away and that her family was grateful that the request for prayer, regardless of one’s faith, was heard and met many times over in the form of an outpouring of compassion from a community of friends and strangers. She said it brought comfort and a sense of being witnessed during the family’s time of immense need. Perhaps this same sort of compassionate presence has the potential to heal and assist those suffering with an unimaginable reality and subsequent uncertainty, even if, in the end, we’re met with the limits medicine itself places on the ability to cure.

**Originally published in Elemental, March 2021**

June/July Newsletter!

 

June/July 2021

Welcome to the June/July issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

A forest playground, near Chattahoochee Hills, Georgia, May 2021

Some things that had me wondering this month:

1. COVID and…
Pediatric Multinflammatory multisystem syndrome:  In the Lancet, some good news: the sequelae (long lasting effects) of the initial symptoms may not persist past 6 months.

On masks:  When and where to wear them, by a pubic health expert, in Slate and…could they be here to stay for cold/flu season (I think so), in the New York Times.

Vaccine Hesitancy: Among healthcare workers in the New York Times.

and….

How the pandemic ends, by the indomitable Helen Branswell, in STATNews.

2. Podcasts (and shows) worth listening to/watching 
The best series I’ve watched in a long time is “The Me you Can’t See,” a series on mental health and wellbeing, produced by Oprah and Prince Harry. I especially loved the last episode, which placed a solutions-lens on mental health as well where this issue intersects with other contemporary challenges, such as policing. Make the time to watch!

3.On…reconciling with Canada’s challenging past with residential schools
In the CBC, the discovery of the bodies of 215 Indigenous children, some as young as three, rippled throughout the country. It’s likely there are many similar mass graves across the nation. First comes ‘truth’ and understanding the true scope of this tragic legacy, and then reconciliation. I sense that we’re only beginning to get to the truth bit.

4.Sound (and wise) reflections
~In NiemanLab, why Darnella Frazier, now 18, should win a Pulitzer for her bravery in capturing the tragic death of George Floyd, which had a ripple effect on how we understand systemic racism in policing and more broadly in our society.
~Billy Porter, on sharing his truth as a man living with HIV, in the Hollywood Reporter
~On the Cicadas who are re-emerging after years, in the New York Times.

5.Miscellany 
~I developed a tree pollen allergy last year, and have been sneezing nonstop seemingly this month. Finally, I have my answer, from CTV.

~On brain implants that could translate thoughts into text, in Wired

~For subscribers to STAT+, the investment in healthcare teams, by tech companies.

~From Yahoo, the tragic death of Michael Lewis’ daughter, Dixie (along with her boyfriend, Ross Schultz), in a car accident last week reverberated throughout the literary community. Lewis is one of the most talented narrative nonfiction writers, and I just started his latest: The Premonition, about the pandemic. His podcast, with Pushkin Industries, Against the Rules, is one of my favorites, and last season he described being coached for singing, drawing parallels with Dixie’s experience with her softball coach. May Dixie and Ross rest in peace. 

6.Best tweets of the month goes to…

Adam Grant, on a mantra we need to finally do away with:

“We’ve always done it that way” is not a valid reason for anything. Don’t follow traditions because the status quo is comfortable and change makes you uncomfortable. Question whether past routines are serving you well in the present and guiding you toward a better future.

Rebecca Herbert, on attachment (or…”inosculation”, in the plant world) which continues to be a theme I think about often: 

The thinner tree was cut years ago and the big one has been holding and feeding it since then. They “wake up” together in the spring and “go to sleep” together in the autumn.

An excellent thread by Marie Beecham on cancel culture as a form of intellectualism.

This sums up a lot of the past 18 months with the pandemic: Mike DiCenzo: (a former writer for Jimmy Fallon, the Onion, etc):

Nobody really knows anything. Everyone’s just saying things. But some people say things more confidently than others.


NYC, enlivened, as the storm clouds (of COVID) appears to be clearing! May 2021 

 

In My Own Words…

For Elemental, I wrote about the “re-emergence” effect we may all be experiencing. And for Wired, I wrote about medical reversals, and what they mean in the broader context of our post-COVID world.

This was also a month with additional ‘in person’ reporting in and around New York with sources I couldn’t meet in person a year ago, given the lockdowns. We also cemented the title (On Healing will be the final!) and the subtitle (this was a toss up between two — so stay tuned!) and hopefully I’ll be able to share the cover in the next newsletter.

And a brand new book to be sure to get your hands on, by my friend Barrett Swanson (I’ve linked to his essays in previous newsletter): Lost in Summerland. This interview, in LitHub, is a great as well.

Have a healthy, joyful, and safe June and July!


Amitha Kalaichandran, M.D., M.H.S.

We Must Rethink the Role of Medical Expert Witnesses

The Derek Chauvin trial highlighted a potential way physicians could better serve the criminal justice system

Credit: Getty Images

In the aftermath of the guilty verdict in the trial of Minnesota police officer Derek Chauvin for the murder of George Floyd, a consistent element of many criminal trials came into sharp focus: the role of medical expert witnesses, and the influence they wield in the courtroom, particularly as it relates to determining the cause of death. Within the span of the ensuing weeks, one juror said that the medical expert testimony was particularly influential, and a petition to investigate another medical expert witness’s track record of assessing cases for potential bias, garnered over 400 signatures from concerned physicians. Clearly, it’s worth asking this question: If the broader goal is to improve justice, can the system of using medical expert witnesses be re-imagined? This question can be examined by highlighting three main challenges.

First, the term “expert” is tricky in medicine, as medical science evolves rapidly (COVID is a prime example). Yesterday’s expert could be out of touch with their field of expertise today. Further, the prosecution and defense choose the expert most appropriate for supporting their respective legal strategies, which runs the risk of confirmation bias. At its best, medicine is a group sport; in hospitals, particularly for challenging cases, physicians share their knowledge; debate and discuss a case; and formulate plans in consultation with each other. And when it comes to the determination of death, the standard for group involvement is often higher. For brain death, for instance, two different physicians’ assessments may improve the likelihood of an accurate assessment.

The second issue is that the standard used by the courts to assess whether an expert witness’s scientific testimony can be included differs by state. Several states (including Minnesota) use the Frye Rule, established in 1923, which asks whether the expert’s assessment is generally accepted by the scientific community that specializes in this narrow field of expertise. Federally, and in several other states, the Daubert Standard of 1993 is used, which dictates the expert show their scientific reasoning (so the determination of validity is left to the courts), though acceptance within the scientific community is still a factor. Each standard has its drawbacks. For instance, in Frye, the expert’s community could be narrowly drawn by the legal team in a way that helps bolster the expert’s outdated or rare perspective, and the Daubert standard presumes that the judge and jury have an understanding of the science in order to independently assess scientific validity. Some states also strictly apply the standard, whereas others are more flexible. (The Canadian approach is derived from the case R v. Mohan, which states the expert be qualified and their testimony be relevant, but the test for “reliability” is left to the courts).

Third, when it comes to assessments of cause of death specifically, understanding the distinction between necessary and sufficient is important. Juries can have a hard time teasing out the difference. In the Chauvin trial, the medical expert witnesses testifying on behalf of the prosecution were aligned in their assessment of what killed Floyd: the sustained pressure of the officer’s knee on Floyd’s neck (note that asphyxia is a common cause of cardiac arrest). However, David Fowler, the medical expert witness for the defense, suggested the asphyxia was secondary to heart disease and drug intoxication as meaningful contributors to his death.

An example of a cause being sufficient on its own might be a person who is pushed out of a plane, at 10,000 feet without a parachute. In a case like that, having a preexisting condition is inconsequential to their certain death. An example of a cause being necessary but not sufficient might be an individual with a compromised immune system who is infected with the influenza virus; neither condition alone would typically be lethal, but the combination might well be. With the Chauvin case, the disagreement between the medical expert witnesses was effectively over whether the force used was sufficient to cause Floyd’s death, irrespective of preexisting conditions (akin to the example of being dropped out of a plane) or whether it was only deadly in combination with another condition such as trace amounts of drugs (i.e., more similar to a person with preexisting conditions dying from influenza).

If we had the opportunity to re-imagine how medical expert witnesses might be used more effectively, how would we approach it?

In a 2010 Canadian paper, two scholars made several recommendations, including that these experts share only opinions (based on facts and reasoning, ideally supported by the medical literature) from their area of expertise, make clear where elements may be controversial in the scientific community, avoid confusing jargon during their testimony, and be informed that their primary role is to assist the court by providing testimony that is impartial, as in free from bias.

Arguments to improve how medical expert witnesses serve the justice system have been made by prominent legal scholars such as David Faigman, the Chancellor and Dean and John F Digardi Distinguished Professor of Law at the University of California Hastings School of Law. However, Faigman shared that it remains a challenge to convince the courts to re-imagine this system.

One potential improvement involves vetting medical expert witnesses for potential biases, such as those based on gender or race before they take the stand (Fowler, the medical expert on Chauvin’s defense team, was involved in another similar case, involving the death of a young Black man, which raised concerns, which is leading to a review of his other cases after an open letter signed by over 400 physicians). According to Faigman, currently only good cross-examination may help elucidate these biases during a trial. As well, biases related to compensation could potentially be avoided by instituting a common pool of funding, with a standard rate, though in practice, this would be challenging to put in place.

Another improvement could involve ensuring that courts institute a more stringent application and selection process, in which medical expert witnesses would be required to demonstrate their clinical and research competence related to the specific issues in a case, and where their abilities are recognized by their professional group. For example, the American College of Cardiology could endorse a cardiologist as a leader in a relevant subspecialty—a similar approach has been suggested as a way to reform medical expert witness testimony by emergency physicians. One drawback, according to Faigman, is that courts would be unlikely to fully abdicate their role in evaluating expertise.

Last, instead of medical experts working for both sides, the courts could appoint a panel of medical experts who are required to explain their assessments (which would be part of the record) independently of each other and the opposing legal teams, but also have the panel work together and deliberate on a final assessment. Faigman shared that while this would offer an ideal solution, the courts would still need to decide how best to appoint and compensate this panel.

In any case, borrowing from how medicine works at its best in hospitals, to improve the current model in court may help us better reach our common goal of justice.

Since the time of Chiron, doctors have been viewed as godlike. More recently, and particularly during the pandemic, we realize that physicians have limits to their knowledge. Perhaps no other physician described the fallibility of doctors more profoundly than Roger I. Lee, who served as the president of the American Medical Association. In an essay aptly titled “Are Doctors People?” published in the New England Journal of Medicine in 1944, he wrote:

“We must accept the fact that the community, from the days of folklore and the

medicine man to the present, conceives the medicine man and the doctor as someone apart

from the rest of the tribe or the rest of the community…[but] Doctors are human beings.”

Lee was ahead of his time in his recognition that doctors also have a role to play in ameliorating social ills. Systemic racism is perhaps the most profound of these ills. The Chauvin trial has only furthered the salience and limits of physician expertise and judgement in the criminal justice system. While the verdict was ultimately aligned with the majority of medical expert witnesses, and those physicians who assessed Floyd at the time, it’s on us to make the system better.

**Originally published in Scientific American, May 2021**

May newsletter!

May 2021

Welcome to the May issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

Some things that had me wondering this month:

1. COVID and…
India:  The situation in India is devastating, to say the least. I’ve written about the role of large companies in helping us address the pandemic in North America (I wrote about some ideas in Fast Company last March, and for Medium). After an initial block on raw materials, the US lifted the ban, which was wonderful news. Companies like Salesforce and Apple have also stepped up to help, and the diaspora has spoken out as well (Toronto Star)

Brazil: The plight of COVID children was meticulously described in NBC News — what might explain this pattern in Brazil, but not North America?  And, in the Globe and Mail, the tragic story of Emily Victoria Viegas, a 13 year old who died In Brampton Ontario

Vaccine Hesitancy: Some ideas on how to re-think it, in the New York Times. Two years ago I tackled the challenge more generally in the LATimes — it’s not about knowledge as much as it’s about understanding, the influence of our peers/social network, and our personal experiences intersecting with our values.

The Color Line: I’ve been waiting for someone to take a deep dive into the disproportionate element of race during this pandemic. Ibram Kendi did just that, in The Atlantic, and it’s worth a read.

To Mask or Not to Mask (and risks):  Nikole Hannah Jones’ Tweet suggests that masking may be a social good in more ways than one. For the Globe and Mail, Andre Picard places the salience of risk assessment, as it relates to the vaccines, in perspective.

Organized Chaos: In Canada, a big batch of vaccines from Johnson and Johnson was held back for inspection (note they arrived from the same US factory that was problematic), the National Advisory Council on Immunizations provided mixed messaging regarding two tiers of vaccines, meanwhile the US is looking to expand vaccine eligibility for the Pfizer vaccine to 12-15 year olds (though herd immunity is looking more unlikely).  That said, the W.H.O. had *finally* deemed COVID airborne (GREAT news) just weeks after an urgent an op-ed by the head of the W.H.O. that was timely and important.

2. Podcasts to listen to:
On her Dare to Lead Podcast, Brene Brown’s interview with Michael Bungay Stanier was brilliant. One big take-home (and there were many) was how to handle requests for giving advice, in a way that places the onus on the asker. It made me think a *lot* about  motivational interviewing: the aim being to help clarify the person’s goals, and reminding them of their own agency. Another interview, on the same podcast, with Angela Duckworth was also a worthwhile listen, especially near the end, when both Brown and Duckworth share experiences with envy and how best to channel that sentiment productively.

This Tim Ferris podcast episode, with Balaji Srinivasan, was from the end of March, but I listened to it in early April (late to the party). It’s well worth the 3.5 hour listen (in chunks!). Some highlights: how autonomy can help offset cancel culture, the future of cryptocurrency, and what work/purpose may eventually look like for each of us. I also appreciated Srinivasan’s orientation towards legacy building, and ‘giving back’ after his success.  

While not a podcast, an incredible Audiobook to make time for is: What Happened to You, by Oprah and Bruce Perry (a psychiatrist) which takes a deep dive into trauma. Over the last year I’ve realized how much is secondary to trauma — how we respond to things and how others respond for instance. These traumatic events, as Gabor Mate shared during a chat earlier this year, can seem minor at the time but they all lead to patterns that underlie how we understand the world and how we interact with others and respond to others. It has deepened my understanding of others and myself. The book wraps up with Oprah doubling down on post-traumatic ‘wisdom’ with some words around making ‘trauma your power.’  

3.On…re-examining medical culture (from 2017)
In the American Academy of Family Physicians — a nice framework for shifting medical culture, both as a leader and someone who is being ‘led.’ 

4.Sound (and wise) reflections
~On languishing, by Adam Grant in the NYT (who humbly shared a counterpoint by Austin Kleon)
~Newark police reform seems to have worked, in NJ.com. 
~Why the dental ‘system’ is so broken, in Canada at least, via The Walrus. It’s a great title too.

5.Miscellany 
~From STATNews: while diversity and inclusion efforts have expanded in most industries, medical education/medical schools is not one. And, in Time, how medical journals remain resistant to writing about systemic racism
~Cancel culture x Shame, by Ezra Klein in the NYT. I’d love to see/hear Brene Brown’s take on this topic.
~The history of the Rubik’s cube — I’ll have more to share in due time (it’s briefly in my book)! 

6.Best tweets of the month goes to…

Via Tim Ferris:
“Let me never fall into the vulgar mistake of dreaming that I am persecuted whenever I am contradicted.” — Ralph Waldo Emerson

By @ProductHunt — your brain on Zoom (without breaks)

A lovely cartoon by one of my favorite children’s book illustrators, Debbie Ridpath Ohi on ignoring writing competition, and focusing on your own journey and pace

Viral viral thread on imaginary New Yorker covers — this one made me cry (a perfect depiction of grief).

And by @JamaalBowmanNY
Addiction requires love — not jail.

And last: @EzraKlein, on anxiety

And then came the pandemic. Reality was objectively terrifying, and many of us were trapped inside, severed from social connection and routine, with acres of time to fret. It was a bad mix. I know a lot of people who didn’t have an anxiety problem before, but do now.


In My Own Words…

For the last year, I’ve been perplexed by the role of medical expert witnesses in the criminal justice system. I didn’t have a reason to explore it until the Chauvin/George Floyd trial, and came across an excellent law review paper by David Faigman (Chancellor of UC Hastings School of Law) which got me thinking. It was truly a page turner!! 
I shared my thoughts in an opinion/analysis piece for Scientific American here.

This was a month with lots of *editing* of my first book draft; I completed the second draft in early May. One of the best books I’ve read over the last few months was by Ashley Bristowe, My Own Blood, which explores how, as a mother of a child with a rare health condition, she was able to navigate both the medical world and the personal world. I highly recommend it — we rarely get insight into these struggles from the ‘patient’ side of things.

It’s promising to see that in some places–parts of the US, things are opening up and vaccine rates are high. Canada still has issues with the vaccine supply, and places like India do as well. I had COVID last year and tested positive for antibodies before receiving the first dose of Pfizer — surprisingly I didn’t become ill but will have to see what the second shot will show. I’m feeling more optimistic than I have in over a year that things will start to open up in the Fall in most places in North America. Hopefully the whole world will be in a position to see the end of this terrible pandemic very soon as well — there’s no ‘them,’ just us, and if there was ever a time for vaccine diplomacy and general regard for global health, this is it.

Have a healthy, joyful, and safe month,


Amitha Kalaichandran, M.D., M.H.S.

Actually, Covid Optimists and Pessimists Are Both Right

Mild and dire forecasting models serve different purposes, and can be tricky to interpret. But when they appear similar, it may signal the end of the pandemic.

 

c/o Getty Images

CONSIDER THIS THOUGHT experiment: J is a 55 year-old patient who has smoked two packs of cigarettes a day since he was 22. He has just been diagnosed with stage III non-small-cell lung cancer. His doctor uses a series of methods, including a model, to decide his prognosis.

In Situation 1, his doctor uses the “precautionary principle” and presents the worst-case scenario based on a model of the worst case: J has about six months to live.

In Situation 2, the doctor bases her prognosis on future-projecting J’s present situation, by definition not the worst-case scenario and more “optimistic”: J has another two years to live.

Which scenario is better?

The answer isn’t so straightforward. In medicine, prognostication is fraught with its own challenges and depends largely on the data and model used, which may not perfectly apply to an individual patient. More importantly: The patient is part of the model. If the information used then shifts the patient’s behavior, the model itself changes–more precisely, the weights given to certain variables in the model change either toward a more negative or positive outcome. In the first scenario, J may decide to shift his behavior to make the most of his next six months, perhaps extending it to nine months or longer. Does that mean the model was inaccurate? No. It does mean that knowledge of the model helped nudge J toward a more optimistic outcome. In the second scenario the opposite may happen: J may continue his two-pack-a-day smoking habit, or only cut down to a pack a day, which may hasten a more negative outcome. It’s entirely possible that J in Situation 1 lives for two years, and in Situation 2 lives for six months.

This pattern exists everywhere, from prognosticating climate change to even polling (knowing poll results can affect voting behaviorpotentially changing the outcome). We’ve seen a similar dilemma with Covid-19 pandemic modeling, which may help explain the divisiveness over everything from when the pandemic may end to whether lockdowns are appropriate. Last year, just as the World Health Organization declared Covid-19 a global pandemic, I wrote about uncertainty and risk perception. When faced with uncertainty we defer to experts, but a month later the National Institute of Health’s Anthony Fauci correctly noted that experts are fraught with predicting what was (and still is) a “moving target.”

Over the past few weeks we’ve seen more opinion pieces focused on optimism: that herd immunity will be reached by April, and summer will be more like 2019, wide open and carefree. We’ve also seen how this optimism, based on a “present-day accurate model” can sway behavior: from schools opening (but then locking back down) to Texas’ recent removal of its mask mandate potentially contributing to an uptick in cases. Others have taken a more pessimistic approach, saying it may be another two years until things “return to normal,” and the virus variants are a “whole other ballgame.” Today, in Michigan and in Canada, a potential variant-fueled third wave suggests a less optimistic outlook (for now). We’re all deeply familiar with how this pattern has repeated itself several times over the past year, and even experts disagree (and some have changed tack). It’s more than just bad news bias. But how do we reconcile this dichotomy between the “optimists” and the “pessimists”? It may come down to how we understand the purpose of epidemiological models in general, and the two types of pandemic forecasting models.

Justin Lessler is an associate professor of epidemiology at Johns Hopkins University and is part of a team that regularly contributes to the Covid-19 Forecast Hub. He specifies that there are four main types of models: theoretical, which help us understand how disease systems work; strategic, which help public officials make decisions, including to “do nothing”; inferential, which help estimate things like levels of herd immunity; and forecasting, which project what will happen in the future based on our best guess how the response and epidemic will actually unfold.

When it comes to forecasting models, there are those whose forecasts are not worst-case scenario by definition (thus more optimistic), which aim to describe present-day patterns in transmission and susceptibility and project out, assuming the current patterns stay the same. In these “dynamic causal models” a variety of different variables are added to also include, as University College London based biomathematician Karl Friston described, unknown factors that affect how the virus spreads, dubbed “dark matter.”

Then there are forecasting models guided by the “precautionary principle,” aka “scenario models,” where the assumptions are often the most conservative. These account for the worst-case scenario, to allow governments to best prepare with supplies, hospital beds, vaccines, and so forth. In the UK, the government’s Scientific Advisory Group for Emergencies focuses on these models and thus guides policy around lockdowns. In the US, President Biden’s Covid-19 task force is the closest equivalent, while the epidemiologists and actuaries that appear nonconformist may be the closest we get to a group like the Independent SAGE (which Friston works with).

“The type of modeling we do for the Independent SAGE is concerned with getting the granularity right, ensuring the greatest fit–with minimal complexity–to help us look under the hood, as it were, at what is really going on,” Friston told me. “So, the fundamental issue is namely, do we comply with the precautionary principle using worst-case scenario modeling of unmitigated responses, or do we commit to the most accurate models of mitigated response?”

This gets to the heart of the tension between various “experts.” For instance, epidemiologists like Stanford’s John Ioannidis have tended to be more concerned with modeling the pandemic to accurately explain current patterns (and extending this pattern into the future), which can come off as more optimistic and isn’t typically used to guide policy.

**Originally published in Wired, March 2021**

April Newsletter!

 

April 2021

Welcome to the April issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

**to access all hyperlinks, please subscribe**

Some things that had me wondering this month:

1. COVID and…
~Vaccine hesitancy.  In December I wrote about a hypothesis on scarcity and social proof about potentially overcoming vaccine hesitancy. Recently the WSJ published data on vaccine hesitancy, which appears to be going down on several states — could it be secondary to scarcity and social proof? And what *might* it mean for vaccine hesitancy in general?

~The politics behind pandemics. This, from the New Yorker is an excellent review of Baylor Medicine’s Dr. Peter Hoetz latest book, Preventing the Next Pandemic, and a great reflection on a remarkable career in infectious diseases/global health.

~Design. COVID has impacted the design world in unique way, in the New York Times .

2. Podcasts to listen to:
The On Being podcast is a favorite. Recently host Krista Tippett interviewed psychologist Christine Ryntab about how our mental health has been affected by the pandemic.  

Part 1 (covers mastery vs success) and Part 2 (covers a beautiful term called “aesthetic force”) where Brene Brown, for her Daring Leadership podast, interviews Harvard’s Dr Sarah Lewis. It might be the best set of interviews I’ve listened to in years. It will nourish you and inspire you (and i’m currently listening to Lewis’ gorgeous book The Rise, on audiobook). 

I’ve been listening to poet and musician Morgan Harper Nichols daily for the last 2 weeks. Her 3-12 min episodes are beautiful reflections which leave you with a question. Nichols’ voice alone is incredible, and her instagram account covers her artwork as well. She’s a rising star to watch. 
Some of my recent favorites have been on trusting despite the uncertainty, on our purpose (with lovely) a river analogy, and 7 phrases to help with future worries. 

3.On…forecasting and expertise
This is from the archives of the Atlantic, by the incredible David Epstein (his book Range is a must-read). Here, citing Philip Tetlock’s work, he calls into question ‘expertise’ — indeed it must be a balance. We need experts to guide us, but non-experts help us identify blind-spots. This is a topic I’ve been thinking about a LOT with the pandemic. I’m now left thinking it’s more of an ‘amplification problem.’  Perhaps, with COVID, given the amount of uncertainty and the fast-moving nature of science, the media tends to rely on experts to self-identify. This then leads to many ‘non-experts’ (confident but incompetent, at least as it relates to medicine and public health), who *should* be part of the discussion, but shouldn’t be amplified, get amplified the media.

Recently an economist at Brown received immense criticism (here, here , here, and here, but really — there were lots of important points made) for an article about childhood COVID transmission.  It was inaccurate and simply unwise, as many physicians and epidemiologists identified, but it likely wasn’t intentionally so. The simplest explanation: economists and epidemiologists look at data and value various factors *differently.* As an economist, her views could add to the discussion — it may just be that they should not have been amplified in that fashion, as it drowned out the current recommendations and expert forecasts. It was quickly debunked but the harm cannot be underestimated. Reporters, and others without expertise but who write about a subject, are expected to incorporate expertise into their pieces, in order to report out an issue fairly and accurately. It’s possible that this economist may have avoided the controversy by interviewing epidemiologists in a “reported op-ed” (one that isn’t solely her opinion), as opposed to writing an op-ed from her point of view as, effectively, a non-expert in public health. Perhaps an article on the economic impacts of COVID or how an economist may *think* through the challenge of lockdowns would have been more appropriate.

We must amplify experts who are truly able to comment on the pandemic and make recommendations, and not simply allow the loudest voices (in the room or on Twitter) to prevail. This, ultimately, causes harm to public understanding, and influences behavior in a way that ultimately negatively impacts how the pandemic is handled. Editors and producers, therefore, must also be equally discerning when commissioning op-eds from academics, and ensure their expertise lines up with the subject matter.

4.Sound (and wise) reflections
~A former incarcerated man reflects on solitary confinement — which he suffered through for 18 years — in NYTOpinion 
~The challenge of bullying in healthcare, in the Financial Post 
~The role of trauma in gun violence, in the NYTOpinion
~There were many great pieces about anti-asian violence. This Q+A in the New Yorker and this op-ed by National Book Award winner, Charles Yu, in the LATimes are worth a read

5.Miscellany 
~From the LATimes, the things migrants carried and dropped on their trek across the border for a better life
~The incomparable Dr Eric Topol, for the WSJ, on how science accelerated over the last 13 months
~The plight of child caregivers, in the LATimes
~In the NYT, the incredible life of one of my favorite writers as a child — Beverley Cleary
~One of the best personal essays I’ve read in months, in the Washington Post, about medical error, second opinions, and the limits of medical ‘expertise’ 

6.Best tweet of the month goes to…
A Three-WAY tie:

This thread is inspiring (it’s worth reading in its entirety). 

@JouLee:
We think strength is self-sufficiency— achievement without reliance on others. We think that if someone else gains, we lose. But intertwined, we all go further. This is the secret of Silicon Valley. Help others, ask for help, and collective strength multiplies.

@gradydoctor:
Reflecting on these statements from 2 good friends in academic medicine this week: 1. “There HAS to be a consequence between nothing and professional death.” 2. “Healing HAS to include restorative justice–which begins with accountability.” Yeah. That part.

In My Own Words…

This was a month with lots of writing, and the next few weeks will be dedicated to my book revisions (due in 3 wks!). For Medium‘s Coronavirus vertical, I wrote a primer about the AstraZeneca vaccine, clots, and concerns about causality. For Elemental, I examined the role of prayer in healing, inspired by the story of Molly (that many of us were inspired by in February). Last, for Wired I tackled an issue that has been on my mind for many weeks: the puzzle of pandemic prognostication (and why some see things through an optimistic lens, whereas others are more concerned) — I make mention of epistemic trust and the issue I discuss above (point #3).

Also, a personal one from the archive (2017), about my grandfather, who has been on my mind late, in Hektoen International.

My time in Vancouver is soon coming to an end (as, sadly, variants are taking hold). It has been such an incredible place, with so much natural beauty, to spend time in over the last 8 months.

 
Have a healthy, joyful, month,


Amitha Kalaichandran, M.D., M.H.S.

A Physician’s Primer on Covid-19, Clotting, and Causality

How to make sense of recent concerns about the AstraZeneca vaccine

Last week, several European countries paused their use of the AstraZeneca vaccine due to concerns about clotting and bleeding risks. Though the World Health Organization (WHO) and European Medicines Agency (EMA) have both said that it is safe to use, most countries have resumed using the vaccine, and the company released data on Monday showing it is 79% effective in preventing symptomatic disease in the United States, many people may still be wondering about the risks. There are five major things to clear up when understanding the concerns about blood clots.

1. What are clots?

When most people think of blood clots, they think of a scab on the skin or clots in menstruation: congealed, thickened blood. In medicine, we’re talking about something more serious, involving the blood that circulates in our veins and travels from the tissues to the lungs to get reoxygenated. Blood clots are a general term for what’s known as deep vein thrombosis (DVT) and pulmonary embolism (PE).

Think of DVTs as blood clots that are often found in the calves or in the arms. Sometimes they resolve on their own, but they become dangerous when they break off and travel through the circulation and into the lungs, causing a PE, which in turn causes chest pain, decreases oxygen, and can lead to death. Sometimes DVTs can break off and travel backward to the heart and through the body again, making their way into the brain and causing a stroke. This is called a paradoxical embolism. A more rare clot in the brain is called a cerebral venous thrombosis (CVST). CVSTs may be the main clot of concern associated with the AstraZeneca vaccine. DVTs, PEs, and CVSTs are medical emergencies.

2. How do clots form?

Most of the time, blood clots form in order to help us heal from wounds — injured tissue, internally or externally. Their formation involves the “coagulation (fancy word for clotting) cascade,” which comprises the extrinsic pathway, intrinsic pathway, and common pathway. The extrinsic pathway refers to factors in the coagulation cascade that are external or extrinsic from blood when studied in a test tube. The intrinsic pathway refers to factors in the cascade that are found in the blood when studied in a test tube.

These pathways require many components to work together effectively, including various clotting factors, most of which are named using Roman numerals and some that aren’t, like protein tissue factor (TF) and Von Willebrand factor (VWF). Other proteins block abnormal clots from forming, so they are said to have “anticoagulant” effects. These include Protein C, Protein S (both work with Vitamin K), and antithrombin III.

Some individuals bleed more easily than others. This can be due to deficiencies in coagulation factors — Factor VIII and Factor IX deficiencies, for instance, cause hemophilia, as does a deficiency in VWF. Other people have a lower platelet count. Since platelets are important to forming a “clotting plug,” which helps prevent blood loss by temporarily sealing an injured blood vessel, a dip in platelets often means bleeding risk may increase.

3. Who is at risk of clots?

Glad you asked. First, anyone with a deficiency in an anticoagulant is at risk. Put another way, anyone who doesn’t have clotting blockers or who clots easily is at risk. An individual with antithrombin III deficiency, for example, would typically clot more easily.

But someone can have perfectly normal coagulation factors and a perfectly well-oiled coagulation cascade and still be at risk. Many athletes (as I’ve written about previously) fall into this category. This brings us to Virchow’s triad. Over a century ago, the German scientist and physician, Rudolf Virchow, described three components that increase the risk of a blood clot.

The first is “venous stasis,” which refers to moments when the blood sitting in our veins is stagnant. Imagine honey or ketchup in a squeezy bottle that’s stuck because it’s been sitting around. The way ketchup or honey congeals is similar to how stagnant venous blood forms. Except in the body, this can lead to a clot. In humans, this happens when we are stagnant. Long flights where we aren’t moving around is a common situation, but so is lying in a hospital bed for days on end, which is why many patients receive a blood thinner and are encouraged to move around.

The second component is vessel injury. If a blood vessel gets injured, the body responds by forming a clot, much as it would if you injure your skin through a scrape or a dog bite. Except when this happens in the body, there’s a chance the clot can become large and break off, blocking vessels and preventing blood (and therefore oxygen) from reaching the tissues, which can be deadly when it comes to the lungs or brain. These blood vessel injuries often happen during surgery.

The third factor involves other factors that increase hypercoagulability, which can refer to everything from cancer to inflammatory disease to being on estrogen hormone therapy (like the birth control pill). The mechanisms vary, but they are generally due to the impact on components of the coagulation system that drive it toward more clotting and away from anti-clotting.

4. So, how does this explain the concern with the AstraZeneca vaccine?

Everything! We’re almost there. Let’s get some facts straight first. First, the incidence of DVT and PE, due to the issues described above, is about one per 1,000 people per year. For CVSTs, it’s even more rare: five per 1 million. This is the normal pre-pandemic and pre-vaccine incidence and reflects individuals at risk due to Virchow’s triad and issues with their coagulation system.

Back to the vaccines. Robust vaccine monitoring systems in many countries specifically look for potential adverse events after the vaccine, as part of what is called “active surveillance.” In general, however, we don’t have active surveillance for blood clots. No one calls families randomly to ask if anyone has had a blood clot. So, the fact that about 37 people who got the AstraZeneca vaccine have reported blood clots, out of 5 million who received the vaccine, doesn’t necessarily mean it’s caused by the vaccine. In all likelihood, these same 37 people would have had the same blood clot even if they weren’t vaccinated. And this is likely, given that the rate isn’t particularly high, compared with the baseline risk of blood clots. While the year still has nine months left, the current rate is about 0.006 per 1000 people per year for clots in general, which is lower than baseline.

It’s possible, given that the AstraZeneca vaccine is generally easier to store and manufacture in larger volumes (e.g. by India), that more people in total have received it. If that is the case, it may seem like the AstraZeneca vaccine is associated with more clots compared to the other vaccines, but the reality could be that more people have received it, period.

The Pfizer/BioNTech vaccine has been given out in 72 countries, and AstraZeneca to 71 as of March 18, but the number of people who have received it in those countries is not known. If each vaccine were distributed with the same frequency, it would be much more straightforward to compare the rate of adverse events, and it’s possible we would see the same pattern with them (which isn’t much of a pattern at all if it’s less than or equal to the baseline risk).

This is where the Bradford Hill criteria of causation comes in. They essentially say that temporality — the fact that an outcome comes after an exposure (in this case, an adverse event comes after a vaccine) — isn’t sufficient to prove causality, for the same reason that wearing a yellow T-shirt a few hours before the sun comes out doesn’t mean your T-shirt caused sunshine. We need more. Specifically, a biological gradient and plausibility: A biological explanation for the cause, much like we know that smoking causes lung cancer because the elements in cigarette smoke are known to be carcinogenic (even in a lab, they can cause mutations in lung cells that result in cancer).

5. Putting it all together — three key questions

Now that you’re an expert in clotting and causality, we can ask three crucial questions.

The first is whether the incidence of blood clots is statistically significantly higher among those that received the AstraZeneca vaccine compared to those that received no vaccine or another vaccine. (Statistically significant means that it’s unlikely to be due to chance.) Here’s the easiest way to think of it: In a random sample of 1,000 individuals, half of whom received the AstraZeneca vaccine and half of whom received another vaccine or no vaccine, does the AstraZeneca group show a statistically significant increased incidence of DVT, PE, or CVST? When testing a large number of rare events, the Bonferroni correction must also be applied to avoid the erroneous finding of statistical significance when testing several things, which apparently was missing from the EMA’s initial work.

The second is whether the dip in platelets observed in people who got the AstraZeneca vaccine is different from what is seen with other vaccines and viruses. Viruses, in general, can sometimes cause temporary dips in platelets (known as thrombocytopenia), and vaccines that are made from inert viruses may also do this. Though they usually cause a mild decrease in platelets, a severe decrease can be concerning and can cause a paradoxical overactivation of platelets, which can cause clots.

The third is whether there is a component in the AstraZeneca vaccine that would impact the coagulation cascade, specifically the hypercoagulability element of Virchow’s triad. This seems unlikely as most vaccine adjuvants (which boost the “immunogenicity”) and stabilizers are inert, meaning they don’t have medicinal or biological impacts. Alternatively, finding other biological mechanisms to explain the body’s abnormal response to the vaccine is also possible.

In summary, it’s unlikely that the clotting issues discovered by active surveillance are caused by the vaccine. However, it’s understandable why some countries are pausing vaccine administration until the above three questions, and possibly others, are answered.

The WHO continues to back the vaccine, while the EMA simply wants to add a warning, and countries like Canada are considering updating its guidance. The crucial thing to understand is that in a battle of risks, the harm from halting a vaccine campaign aimed at putting a stop to a deadly pandemic, which has a risk of mortality and long-term complications, appears to be much higher than the risk of blood clots.

March newsletter!

March 2021
**To access all of the hyperlinks, please subscribe**

Welcome to the March issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being

 

 

 

 

 

 

 

“Two days, Two seasons” (Kitsilano, Vancouver BC, February 14th vs February 13th, 2021)

 

 

 

 

Some things that had me wondering this month:

1. COVID and…
~A new vaccine. The Johnson & Johnson COVID vaccine is now available in the US (hopefully in Canada soon). How does it stack up against Moderna and Pfizer (and AstraZeneca)? This might be the wrong question when scarcity is at play: take what you get, as this NYT op-ed advises. Remember: the vaccine is intended to prevent severe disease, i.e. disease that would require a hospitalization/ICU visit or worse: death. It may not be perfectly effective at preventing infection. The flu vaccine is similar, though often has much lower effectiveness. But in general, those vaccinated with the flu vaccine are at a much lower risk of severe disease, even if they do have mild flu symptoms.

~Vaccine diplomacy. This will continue to be a topic to watch closely, and one I’ve been pondering since the Summer when I received a press release about an Indian manufacturer planning to ramp up production of a vaccine (which ended up being the Astra Zeneca vaccine). India specifically has played a major role over the last 15 years in terms of drug manufacturing: especially as it relates to anti-retroviral drugs, and facilitating a price drop which improved global access.  India has manufactured vaccines for global health (e.g. polio) as distributed by organizations like GAVI, WHO, UNICEF, etc. But this is the first time to my knowledge that India is playing a role in manufacturing vaccines for the ‘developed’ world.  So not only is Jamaica receiving shipments, but so is Canada.    The editors of the NYT Opinion section penned an excellent op-ed on the theme here. My question: will India then be able to leverage other interests (e.g. politically, trade/economic) with recipient countries? And what are the potential pitfalls and opportunities?   A handy comparison: the role China played in providing PPE to affected countries, and the potential downside regarding accountability as it relates to investigations into the virus origins in the country.

~On reopening schools. It remains a tricky debate. I like Dr Leana Wen’s take in the Washington Post.  Side note: I spent my 32nd birthday in Charleston, and Dr Wen happened to be there (story for another time, but she’s fabulous!)

Screening for health conditions. There’s no doubt that there are several externalities secondary to the pandemic. One big one that doesn’t get discussed enough: the negative impact on screening. This piece, in the NYT, tackles it head on.

~Children. A well presented and reported piece on the youngest victims of the pandemic in the Post — even if children rarely suffer from severe disease, they are impacted in other long-lasting ways.

~The best essay I’ve read (about COVID since the pandemic began), by none other than Dr. Siddhartha Mukherjee. This one is about the mystery behind the low death rate in India in the New Yorker (followup with my favourite New Yorker piece period, from 2017, Cancer’s Invasion Equation, also by Dr. Mukherjee)

2. Podcasts to listen to:
This episode of Brene Brown’s podcast features one of my favorite thinkers, Adam Grant.
Here they interview each other in a sense, and Grant gets into the topic of his latest book, “Think Again,” while also sharing a variety of anecdotes about his career and life decisions.

And because she’s utterly delightful, Fran Lebowitz interviewed by Kara Swisher on Sway is well worth the laughs and incredulity, if only for her line comparing herself to Helen Keller.

3.On…systemic racism in the 1950s and 2021
~Harry Jerome is a Canadian that I, and many others, never learned about in school. As a Black man attending a mostly all-white school in Vancouver in the 1950s, he had rocks hurled at him. His story of that time is captured here, in the CBC.  A track star that went on to set several world records, Jerome sadly died in 1982. Now Vancouver is finding a way to honor him.

~This is an important read from StatNews‘ Theresa Gaffey, about a big story that was trending on Twitter earlier in February. A program director, who happened to be a Black woman, was dismissed from her position after flagging issues of systemic racism. This topic in general is a sad and very real issue in academic medicine, affecting residents, but also, clearly, staff as well.  Of note, Gaffey is a multimedia producer but I hope she stays on this beat (medical education) as this article was so well reported, covering the nuances particularly well.

~And for GQ, the incomparable Wesley Lowery on how one police department, in Ithaca, New York is attempting reform. It may be a model for others.

4.Sound (and wise) reflections
~From NYTMag, this profile of Kazuo Ishiguro is simply sublime. What a brilliant mind

~The type of love that makes you happiest, in the Atlantic

~From ESPN, on injury and resilience, through the story of basketball player Azzi Fudd

~One of the most harmful questions you can ask children, by Adam Grant for CNBC

5.Miscellany 
~From NYTOpinion about nurses, and what the pandemic means for the future of nursing. We rarely hear from other frontline workers (other than physicians), so this was illuminating for me. That said, someone on Twitter, who happens to be a nurse, flagged to me that that article was not inclusive, and my sharing of it failed to amplify this issue. And, well, I agree (I have my own blindspots). That opinion piece did not include the fact that in many cities most hard hit, nurses of color (mostly women) have disproportionately been affected. So I also share this article, in CNN: about the toll on Filipino nurses in particular, though the same may be said of Caribbean-American nurses, Latin-American nurses, and so forth. It also reminded me of why I mentor with the Op-Ed project, to help ensure that under-represented voices get heard.

~The tragic story of Joe Ligon, which broke my heart and I *still* can’t wrap my head around: to be captive for THAT many years, and now released. Unimaginable.

~The death of groundbreaking cancer researcher, Dr. Emil Freireich hits hard for anyone in pediatric medicine. He was a trailblazer to say the least, and highly disagreeable in his approach as a pediatric oncologist and researcher. He didn’t care much for the status quo: his focus was on finding a treatment for childhood leukemia, which he did.  His obituary in the NYT is a must read.

6.Best tweet of the month goes to…
A compelling speech by Ryan Leaf, about the NFL’s failure to acknowledge mental health issues. As I write this another former player, Louis Nix, has died (though the cause has not been confirmed).

I don’t know who needs to hear this, or if I just needed to say it, but I will not continue to stand by and watch my brothers disappear because the multi billion $$$ corporation won’t do the right thing.
@nfl @NFLPA do something!! #igoturback #nflbrotherhood

And a thread by the incredible writer and musician Morgan Harper Nichols, about her recent diagnosis of autism, as a reminder of how women are often diagnosed late, or misdiagnosed:

Last Saturday, after a very long journey, I was officially diagnosed with autism and I just want to share my experiences here for anyone else out there whom it could help (a lengthy thread)

In My Own Words…

My lockdown obsession: colorful heritage hen eggs by Black Rooster Farms, Langley BC
January 2021  (these aren’t painted by the way– the colors are REAL!)

 

This month, I had the pleasure of being interviewed by influencer Camille Styles, on finding our purpose. I also participated in the “SoMeDocs writers conference” which was really fun (some great questions).

Other than that, I’m knee deep in book edits, with revisions due in April, and polishing off a textbook chapter I’m co-writing with a friend and colleague, Dr. Daniel Lakoff (emergency medicine physician with NYP Hospitals).  I will have a piece out next week, which I’ll include in next month’s newsletter.

To end I’d like to highlight Andre Picard’s book on elder care arrived this week, and is timely and important. For my American readers: Picard is a must follow, as arguably the most prominent health journalist in Canada, and longstanding columnist for the Globe and Mail. He shares his commentary thoughtfully and wisely.

Have a healthy, joyful, month,


Amitha Kalaichandran, M.D., M.H.S.