Occasionally, you get handed a question you know little about, but it’s clear you need to know more. Like most of us these days, I was chatting with my colleagues about the novel coronavirus. It goes by several names: SARS-CoV-2, 2019-nCoV or COVID-19 but I’ll just call it COVID. Declared a pandemic on March 12, 2020 by the World Health Organization (WHO), COVID is diagnosed by laboratory test – PCR. The early PCR test used in Wuhan was apparently low sensitivity (30-60%), lengthy to run (days), and in short supply. As CT scanning was relatively available, it became an importantdiagnostic tool for suspected COVID cases in Wuhan.
The prospect of scanning thousands of contagious patients was daunting, with many radiologists arguing back and forth about its appropriateness. As the pandemic has evolved, we now have better and faster PCR tests and most radiologists do not believe that CT scanning has a role for diagnosis of COVID, but rather should be reserved for its complications. Part of the reason is the concern of transmission of COVID to other patients or healthcare workers via the radiology department.
But then someone asked: “After you have scanned a patient for COVID, how long will the room be down?” And nobody really could answer – I certainly couldn’t. A recent white paper put forth by radiology leaders suggested anywhere from 30 minutes to three hours. A general review of infection control information for the radiologist and radiologic technologist can be found in Radiographics.
So, let’s go down the rabbit hole of infection control in the radiology department. While I’m a radiologist, and will speak about radiology-specific concerns, the fundamental rationale behind it is applicable to other ancillary treatment rooms in the hospital or outpatient arena, provided the appropriate specifics about THAT environment is obtained from references held by the CDC.
I got asked the other day to comment for Wired on the role of AI in Covid-19 detection, in particular for use with CT scanning. Since I didn’t know exactly what resources they had on the ground in China, I could only make some generic vaguely negative statements. I thought it would be worthwhile to expand on those ideas here, so I am writing two blog posts on the topic, on CT scanning for Covid-19, and on using AI on those CT scans.
As background, the pro-AI argument goes like this:
CT screening detects 97% of Covid-19, viral PCR only detects 70%!
A radiologist takes 5-10 minutes to read a CT chest scan. AI can do it in a second or two.
If you use CT for screening, there will be so many studies that radiologists will be overwhelmed.
In this first post, I will explain why CT, with or without AI, is not worthwhile for Covid-19 screening and diagnosis, and why that 97% sensitivity report is unfounded and unbelievable.
Next post, I will address the use of AI for this task specifically.
It took a 125 nanometer virus only a few weeks to move American healthcare from the twentieth to the twenty-first century.
This had nothing to do with science or technology and only to a small degree was it due to public interest or demand, which had both been present for decades. It happened this month for one simple reason: Medicare and Medicaid started paying for managing patient care without a face to face encounter.
Surprise! In the regular service industries, businesses either charge for their services or give certain services away for free to build customer loyalty. In healthcare, up until this month, any unreimbursed care or free advice was provided on top of the doctors’ already productivity driven work schedules.
By HOWARD LUKS MD, JOEL TOPF MD, FACP, ETHAN WEISS MD, CARRIE DIULUS MD, NANCY YEN SHIPLEY MD, ERIC LEVI MBBS, FRACS, BRYAN VARTABEDIAN MD
“EVERYTHING WE DO BEFORE A PANDEMIC WILL SEEM ALARMIST. EVERYTHING WE DO AFTER WILL SEEM INADEQUATE”
Last updated 3/18/2020.
Why are we writing this?
The COVID-19 pandemic has reached a point where containment is no longer possible. The COVID-19 threat is real, and rapidly getting worse. Many of you are very nervous, some are unsure of the validity of the information you are reading. As physician leaders, we felt it was important to craft a resource you can rely on as being scientifically accurate and one which contains as much actionable information and guidance as possible.
Accurate, actionable information during an epidemic can save lives. Physicians are on the front line of this epidemic. Not only are we treating the sick, but we are also cringing at the misinformation spread through both traditional broadcast and social media. Evidence matters. Unfortunately, evidence is often slow, methodical, and boring and has a tough time against clicky headlines and exaggeration. We believe that an accurate representation of the current COVID-19 pandemic followed by a set of actionable steps you, your loved ones, politicians and local officials can utilize is of paramount importance and ultimately could save tens of thousands of lives.
COVID-19 isn’t just the flu?
COVID-19 has been described by some as “just a cold”, or just like the common flu. COVID-19 is not the common flu. COVID-19 is an order of magnitude worse than the flu. The fatality rate is approximately 10 times worse than the flu.
The flu spreads from September through April in the US, and June through August in the Southern Hemisphere. Yes, it does cause severe illness in many, but it does so over a longer time course. Time is a variable that is working against us during this COVID-19 outbreak. COVID-19 victims will be presenting to a hospital in need of critical care at a rate that is far higher than occurs with the flu.
In addition, these patients will be requiring hospital treatment over the course of a few weeks rather than the 3-4 months of a typical flu season. The healthcare system in the USA is not ready to handle tens of thousands or hundreds of thousands of people over a short time frame. In Italy, the healthcare system buckled under the strain and the healthcare teams are now forced to make horrible life and death decisions.
As the globe faces a novel, highly transmissible,
lethal virus, I am most struck by a medicine cabinet that is embarrassingly
empty for doctors in this battle. This
means much of the debate centers on mitigation of spread of the virus. Tempers flare over discussions on travel
bans, social distancing, and self quarantines, yet the inescapable fact remains
that the medical community can do little more than support the varying
fractions of patients who progress from mild to severe and life threatening
disease. This isn’t meant to minimize the
massive efforts brought to bear to keep patients alive by health care workers
but those massive efforts to support failing organs in the severely ill are in
large part because we lack any effective therapy to combat the virus. It is akin to taking care of patients with
bacterial infections in an era before antibiotics, or HIV/AIDS in an era before
It should be a familiar feeling for at least
one of the leading physicians charged with managing the current crisis – Dr.
Anthony Fauci. Dr. Fauci started as an
immunologist at the NIH in the 1960s and quickly made breakthroughs in
previously fatal diseases marked by an overactive immune response. Strange reports of a new disease that was
sweeping through the gay community in the early 1980’s caused him to shift
focus to join the great battle against the AIDS epidemic.
Healthcare today, in the broadest sense, is not a benevolent giant that wraps its powerful arms around the sick and vulnerable. It is a world of opposing forces such as Government public health ambitions and more or less unfettered market ambitions by hospitals and downright profiteering by some of the middlemen who stand between doctors and patients, such as insurers, Pharmacy Benefits Managers, EMR vendors and other technology companies.
Within healthcare there is also a growing, more or less money-focused sector of paramedicine, promoting “alternative” belief systems, some of which may be right on and showing the future direction for us all and some of which are pure quackery.
I stand by my conviction that physicians must embrace the role of guide for their patients. If we see ourselves only as instruments or tools in the service of the Government, the insurance companies or our healthcare organizations, patients are likely to mistrust our motives when we make diagnoses or recommend treatments.
As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today.
Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.
Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:
my own perspective, I have no reservations about accepting any, or all of the
foregoing articulations of various qualities, attitudes, and activities of the
physician as legitimate representations of important attributes for the
trustworthy professional. In fact, I find it difficult to choose one list over
others, since they each in turn seem to refer largely to the same general set
of admirable qualities. While we in medicine might see these as our lists of
the desirable attributes of professionalism in the physician, as the father of
an Eagle Scout I know that Boy Scout leaders use a very similar list to
describe the important qualities of scouts: ‘A Scout is trustworthy, loyal,
helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean,
reverent (respecting everyone’s beliefs).’ I make this observation not to
descend into parody, but to make a point. These various descriptions are so
similar because when we examine the field of medicine as a profession, a field
of work in which the workers must be implicitly trustworthy, we end by
realizing and asserting that they must pursue their work as a virtuous
activity, a moral undertaking.”
Tesla is now, by market cap, the second largest auto manufacturer (after Toyota). Its market cap exceeds U.S. auto makers Ford, G.M., and Fiat/Chrysler — combined. This despite selling less than 400,000 vehicles in 2019, a figure that is more than the prior two years combined.
Tesla has made its bet on the future of electric cars. It didn’t invent them. It isn’t the only auto manufacturer selling them. But, as The Wall Street Journalrecently said:
Investors increasingly see the future of the car as electric—even if most car buyers haven’t yet. And lately, those investors are placing bets on Tesla Inc. to bring about that future versus auto makers with deeper pockets and generations of experience.
A recent analysis
suggested a big reason why, and its findings should give those in healthcare
some pause. Tesla’s advantage may come, in large part, from its supply
In the 1970s, Jean Whitehorse, a member of the Navajo Nation, went to a hospital in New Mexico for acute appendicitis. Years later, she found out the procedure performed was not just an appendectomy – she had been sterilized via tubal ligation. Around the same time, a Northern Cheyenne woman was told by a doctor that a hysterectomy would cure her headaches. After the procedure, her headaches persisted. Later, she found out a brain tumor was causing her pain, not a uterine problem. Like Whitehorse and the Northern Cheyenne woman, thousands of Native American women have suffered irreversible changes to their bodies and psychological trauma that continues to this day. Most medical providers are unaware of our own profession’s role in implementing these racists policies that have direct links to the Eugenics movement.
Eugenics was a “movement that is aimed at improving the genetic composition of the human race” through breeding. From its origin in 1883, eugenics became the driving rationale behind using sterilization as a tool to breed out unwanted members of society in the United States. With the 1927 Supreme Court case Buck v. Bell permitting eugenic sterilization, 32 states followed suit and passed eugenic-sterilization laws. Although the outward use of sterilization declined after World War II because of its association with Nazi practices, sterilization rates in poor communities of color remained high throughout the United States.
Burnout among healthcare professionals is at an all-time
high. Its drivers include longer work hours, the push to see more patients,
more scrutiny by administrators, and loss of control over our practice. We seem
to spend more time with the electronic medical record and less time
face-to-face with our patients.
I have faced burnout personally. My son passed away at the
age of 29, which was beyond painful. At the same time, I felt burdened by the
growing number and complexity of metrics by which I was judged at work. Days in
the operating room and intensive care unit seemed more and more exhausting, and
my patience was becoming shorter and shorter. I was fortunate to have had a long-standing
meditation practice as well as sabbatical time that I used to decompress and
re-evaluate my career. Many of us are not so lucky. More than half of
physicians have serious signs of burnout, and more than one physician commits
suicide every day.
So many of us feel burned out these days because in our
rapidly changing profession we are asked to do more for less and with
inadequate resources. We suffer from exhaustion, self-criticism, and worry
about what will happen next to our practice, our families, and ourselves. If we
want to save our practices, patients, marriages- even our lives, we must
acquire personal resilience.
Fortunately, we can increase our resilience and happiness and reverse burnout by embracing a few simple principles—Gratitude, Acceptance, Intention, and Nonjudgment (GAIN)—that we can put into motion in our everyday lives at the hospital, at home, or wherever we are.