The Moon, Measles and Misinformation

Saturday marks the 50^th anniversary of the lunar landing.  On July 20, 1969, Neil Armstrong and Buzz Aldrin became the first humans to walk on the moon.  This is fact.  Somehow, though, conspiracy theories about the moon landing being a hoax remain alive.  Much time and effort has been spent debunking these wayward theories.

There is psychological link between the moon landing hoax and a pattern of thought that influences the debate about current, serious issues such as the re-emergence of communicable diseases like measles and the global crisis of climate change.  The cognitive gymnastics that lead to support of the anti-vaccine movement and to climate change denialism appear to be grounded in the misapplication of the concept of proof, and a lack of understanding of how science works  (although to be sure, that may not be the only reason, as breeding misinformation may be advantageous to one’s economic position, as can be seen in the refusal to address climate change).  This was stated well by Jeremy Shapiro, a psychologist at Case Western Reserve University: “Proof exists in mathematics and logic but not in science. Research builds knowledge in progressive increments. As empirical evidence accumulates, there are more and more accurate approximations of ultimate truth but no final end point to the process. Deniers exploit the distinction between proof and compelling evidence by categorizing empirically well-supported ideas as ‘unproven.’ Such statements are technically correct but extremely misleading, because there are no proven ideas in science, and evidence-based ideas are the best guides for action we have.”

Watching a 72-year-old Buzz Aldrin punch an aggressively obnoxious moon landing hoaxer in the face might be satisfying (video available online), but unfortunately that approach won’t make any headway in the battle against scientific denialism. You may have heard before that facts don’t change the mind of someone with a strongly held belief.  That’s in part due to confirmation bias: we give little credence to evidence that contradicts our beliefs and weigh heavily any evidence that confirms them (a cognitive bias we have to combat in the diagnostic process). We overlook inconvenient truths and arguments to the contrary, allowing our established opinions to become entrenched.  Schmid and Betsch recently published “Effective strategies for rebutting science denialism in public discussions,” in which they described a series of experiments showing how certain approaches fared in counteracting the spread of misinformation about vaccination. They found that using topic rebuttal (opposing misinformation with facts) and technique rebuttal (unmasking the flawed methods of argument, like cherry-picking data, etc) were both effective, but combining the rebuttal approaches was not additive. A nice review can be read in the Scientific American article “How to Debate a Science Denier” by Diana Kwon. As if to emphasize the point, a study by the Yale Program on Climate Change Communication and George Mason University Center for Climate Change Communication looked at whether or not Americans were changing their mind about global warming; they found a small but meaningful percentage of people had changed their mind to recognize it as a serious problem.

Regarding Climate Change, the ACP outlined its stance in a May 2016 Position Paper and there is additional information in the Advocacy section of acponline (Climate Change Toolkit). ACP has also recently come out in support of the Vaccine Awareness Campaign to Champion Immunization Nationally and Enhance Safety (VACCINES) Act. This is bipartisan legislation that would provide federal funding for surveillance of low vaccination rates by the Centers for Disease Control and Prevention and outline a national public messaging campaign informed by this research to help improve vaccination rates.

Parenthetically, there’s an interesting moon-measles connection; one you might remember if you saw the movie Apollo 13.  Charlie Duke, a member of the back-up flight crew, contracted measles; he exposed Ken Mattingly, a first-string crew member who was non-immune. Because of fear that he might develop the disease while in space, Mattingly was grounded, to be replaced by Jack Swigert. Some believe that contributed to the safe return of the ill-fated mission because of Swigert’s particular knowledge of command module emergency procedures and Mattingly’s particular engineering skill which helped the flight crew from the ground, but that is just speculation (and not a testable hypothesis!).

-Rob Nardino, MD, MACP

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Preventing Firearm Related Violence

I’ve written on the topic of firearm violence before; in December 2015 when ACP was advocating for lifting the ban on federally funded research into this public health issue and again in May 2016 with the online publication of the Annals article Yes, You Can: Physicians, Patients, and Firearms, which clarified existing laws that had a bearing on talking to patients about firearms.  In October 2018, the ACP released a position paper on reducing firearm injuries and deaths; and now, in the current issue of Annals of Internal Medicine, the In the Clinic article is dedicated to the topic.  Not coincidentally, this Friday was also National Gun Violence Awareness Day.  Therefore, it seems like a good time to revisit the issue.

In Preventing Firearm-Related Death and Injury, Pallin and colleagues remind us that in the preceding decade there were more civilian firearm deaths than all combat deaths in World War II. In 2015, the age-adjusted firearm-related mortality rate exceeded that related to motor vehicles accidents, the first time that has occurred. Suicide by gunshot continues to escalate. And while public mass shootings grab the headlines, they account for only 1-2% of firearm related deaths.  Nearly 60% of firearm associated deaths are suicides.  When a gun is chosen for suicide, it is successful 90% of the time.  These are sobering numbers that we have to confront. The authors go on to discuss screening, focusing on identification of risk. They give useful tips for how to handle conversations with patients about firearms. The article also reviews counseling about safe firearm storage.  The authors mention that Connecticut is one of 15 states with a law that allows judges to issue emergency orders to prevent persons from possessing firearms in situations of acute risk for causing harm to themselves or others (extreme risk protection orders). Experience in our state indicates the orders are especially effective in suicide prevention.

There are a number of online resources provided in the article (“Tool Kit”). In particular, check out the UC Davis “What You Can Do” site where you can find a wealth of information. Garen Wintemute MD, senior author of the In The Clinic article and a leader on the topic, is a driving force behind the site and in encouraging physicians to commit to help reduce firearm-related injuries and deaths. If you are interested and really want to delve into the issue of firearm violence and what to do about it, and you’ve got a couple of free hours every week for the next 6 weeks (who doesn’t?), consider the free course from the Johns Hopkins Center for Gun Policy & Research.

-Rob Nardino, MD, MACP

Let’s hold our elected officials accountable

I have been criticized before for being too political in these posts.  But I maintain that as internists, we have to recognize that the decisions of legislators and policymakers have a profound impact on our country’s health. And, if we’re being honest, the state of affairs in 2019 leaves a lot to be desired:

Over 28 million people in the U.S. remained uninsured.  This is a major contributor to the U.S. lagging behind other comparably wealthy countries in many healthcare quality measures.  Efforts are underway to further undermine the Affordable Care Act, a law that has led to a 45% reduction in the number of uninsured since its implementation. ACP recently released a Position Paper calling for the strengthening of the ACA with efforts to move towards truly universal coverage.  In Connecticut, the House is about to consider a bill that will introduce a state-sponsored option for those without employer-subsidized coverage and who don’t qualify for Medicare.  While of course it will be politically charged, it is good to see someone trying to move the needle on this issue.

Institutionalized discrimination.  It’s unfortunate that this may be the legacy of the current administration.  To be sure, hate, intolerance, xenophobia and religious persecution have a long and sordid history in the U.S., even as we established ourselves as champions of liberty; this consistent conflict is part of our national DNA. It seemed in some respects that we were gradually making progress, although surely not everyone viewed it as such; in fact, depending on your perspective, you might have viewed changes as too radical or not nearly enough/too slow. Nevertheless, now the country appears to be changing direction. It’s particularly disturbing when such attitudes seep into healthcare, like the recent move to eliminate federal rules requiring non-discrimination against transgender persons, and to weaken requirements that clinics accommodate patients with disabilities and with limited English proficiency. I was proud to hear ACP President Robert McLean recently state that “ACP is committed to improving the health of all Americans and opposes discrimination against any patient in the delivery of health care services.”

Catastrophic climate disruption. Deny it at your own peril. It’s understandable that we would like to shun responsibility because it forces some difficult choices. Similarly, one can be forgiven at the individual level for feeling overwhelmed by the magnitude of the problem or needed solutions. But policy makers have the responsibility to address it rather than keeping their heads in the sand.  ACP expressed its support for the Climate Action Now Act, recently passed by the U.S. House of Representatives. This act directs the U.S. to uphold its commitment to the Paris Agreement on Climate Change.  It’s likely to die in the Senate but we should continue to hold our lawmakers accountable for positive action, as advocated in the 2016 ACP Position Paper on Climate Change and Health.

Resurgence of vaccine-preventable diseases.  I recognize there is a struggle when balancing personal liberty versus restricting choice for the good of the whole.  I will state clearly that it is my opinion that when it comes to immunization, I favor protection of public health at the expense of personal choice and that states should be hesitant to grant exemptions for vaccination.  Regardless of your opinion, you should be alarmed that there have been 880 cases of measles this year (as of May 17), which already puts 2019 as the year with the highest yearly incidence in 25 years; this for a disease we declared eradicated in 2000. I would argue that this is not the direction we should be going.

I will skirt the political minefields of firearm safety and reproductive rights for today.  I will simply say that the decisions of some lawmakers are made in service to political expediency or the needs of certain powerful “constituencies” and don’t seem to serve the good of the public.

Our patients need us to not be idle spectators when it comes to health policy.  In fact, the Internal Medicine Milestones that we use for assessing our trainees’ readiness for independent practice include this one: “Demonstrates integrity, honesty, and accountability to patients, society and the profession.” I’ll argue that accountability to society includes advising lawmakers on issues that are within our domain so that they exercise judgment that benefits our health and well-being.  Let’s continue to educate and inform them, and hold them accountable when they let us down.

-Rob Nardino, MD, MACP

Robert McLean of CT Chapter is ACP President for 2019-2020

We are so proud that our chapter’s own Robert McLean is the new President of ACP! You may already know that he is a practicing rheumatologist and Medical Director of Clinical Quality with Northeast Medical Group of Yale New Haven Health, as well as Associate Clinical Professor of Medicine at Yale School of Medicine. He was our chapter’s Health and Public Policy Chair for many years before serving as Governor from 2009-2013. Since then, he has served on the ACP Board of Regents. Below, I am reproducing the profile that was written by Jeff Lyons for ACPIMpact, the Medical Student Newsletter of ACPonline.  RJN

Background
1. I was born and raised in… Born in Chapel Hill, NC, while my father was in dental school at UNC, then grew up in Potomac, MD, in the Washington, DC, suburbs.
2. As a child I was… a typical first-born—bossy over my younger sister, and I was a true child of the 70s (I loved music and movies especially) but fortunately still spent enough time reading and playing sports that my brain didn’t rot.
3. I decided to be a doctor… because I was always interested in science in school, but also loved the social interaction a medical career seemed to involve.
4. The person(s) who influenced me the most… to go into internal medicine was Dr. Ted Woodward, a legend at the University of Maryland School of Medicine, who taught Intro to Clinical Medicine to the first-years, interviewing patients in front of a lecture hall and showing how “patients will usually lead you to the diagnosis, if you let them.” He handed out the Francis Peabody lecture “The Care of the Patient,” which I still have. Dr. Woodward was a teacher and internist role-model extraordinaire.

Career
5. I chose internal medicine because… it combined the intellectual rigor of complex organ system conditions, with the curiosity needed to be a good detective, with the emotional satisfaction of helping patients both with short-term illnesses and with long-term chronic disease management.
6. What I find most rewarding about my career is… the variety my daily activities. I was practicing both primary care medicine and rheumatology for more than 20 years, seeing patients in my office and having the opportunity to teach students and residents in an ambulatory setting. Then in recent years I was lured into some administrative work in the areas of quality and safety. It is a fascinating challenge to combine my medical knowledge with strategy and thinking about change management, at all levels, from the individual behavior of doctors and patients to the various large systems in which we operate.
7. I joined ACP because… I was initially attracted to advocacy early in my career, starting with scope of practice issues in my state of Connecticut and soon after furthered with attendance at my first ACP Leadership Day in DC more than 20 years ago. ACP has become my professional home, allowing me to step out of my practice situation and deal with much larger issues impacting our profession as well as how to improve our health care delivery system for our patients. It has always made me see a bigger picture of health care delivery, and provided me the opportunity to develop a larger sense of purpose.
8. An award or achievement I am proud of is… receiving the ACP’s “Key Contact of the Year” Award in 2006, now called the Richard Neubauer Advocacy Award. Being recognized for advocacy by an organization like the ACP was a tremendous honor. Having the opportunity to carry that further as ACP President will be a thrill.
9. My advice to medical students is… look at the big picture when choosing a specialty. The field must be something that will interest you for many years. But realize that turns (and bumps) along the road are inevitable and embrace opportunities as they arise.

Personal
10. I like people who… are honest, compassionate, and hard-working.
11. My family includes… a wonderful wife who tolerates my foibles and keeps me inspired every day, two sons who keep me humble both intellectually and in athletic endeavors, and my parents and a sister who showed me the wonderful value of laughter and humor.
12. My interests/hobbies are… reading non-fiction including history of medicine (nerdy about details, per my family), travel to interesting places and the geography that entails, skiing with my sons, golf when I have the chance, and movie and music trivia.
13. If I had the time, I would like to learn… to play the guitar.
14. I enjoy listening to… music from 70s and 80s, as well various types of blues and jazz.
15. I enjoy watching… movies (though not enough time) and live sports, especially tennis and squash (sports my sons played).
16. My idea of a great vacation is… touring historic places as well as seeing beautiful natural scenery with my family.
17. Something others may not know about me is… I developed a problematic habit as a kid of liking to collect things (business cards, beer cans, ski mountain patches) that my wife now considers a bit pathologic.
18. If I could be anything other than a physician I would be… tour guide at a sports hall of fame (or the Rock & Roll Hall of Fame, per my sons), or maybe a brewmaster.
19. A person I greatly admire is/was… someone who endured hardship yet appreciated humanity and envisioned a higher purpose, Nelson Mandela.

Internal Medicine 2019

I’ve had the chance to reflect on the national meeting held in Philadelphia two weeks ago.  What a great meeting!  The first highlight was the opening address, which was more of a “fireside chat” between CEO/EVP Darilyn Moyer and Vivek Murthy, former Surgeon General of the United States between 2014 and 2017.  Dr. Murthy has spoken extensively on social isolation, and this was a main focus of the conversation with Dr. Moyer.  This epidemic of loneliness is in part driven by technology and how we use it to communicate with each other (as I write unironically in the blog) but also how with increased connectedness, work spills into time previously reserved for family or socializing with friends. Most striking is that loneliness and weak social connections are associated with reduced longevity comparable to smoking 15 cigarettes a day, and more than that associated with obesity.

The sessions were excellent. Of course, there was the usual problem that multiple sessions you want to attend are happening at the same time.  I definitely made use of the handout availability to catch up on the ones I missed.  I did make it to the Ananda Prasad Lecture on the Adverse Physiologic Effects of Sleep Loss, given by Christopher J. Lettieri, who is Professor of Medicine at the Uniformed Services University of the Health Sciences.  He began with physiology and discussing the opposing drives for wakefulness and sleep. He talked about the recently discovered glymphatic system, which functions in the CNS during sleep to clear waste and metabolites from the brain. By now, I think you are aware of the detrimental effects of chronic sleep loss. Dr. Lettieri emphasized that insufficient sleep is associated with an increased risk of cognitive dysfunction; diminished REM sleep is a strong predictor for developing Alzheimer’s disease.  He also pointed out the link between cardiovascular disease and chronic sleep loss.

I also wanted to mention “Media in Healthcare: Podcasts, Social Media, and Beyond” featuring Matthew Watto, one of the hosts of The Curbsiders podcast.  The opportunities for integrating social media in healthcare, particularly in medical education, are many.  Many of you probably already listen to podcasts or use Twitter or LinkedIn to keep track of goings-on in various areas of medicine.  You might already by a #FOAMed expert (FOAM = Free Open Access Medical education, #FOAMed is the conversation) – if not, maybe it’s time to join in!   Connecting back to Internal Medicine 2019, if you missed it, check out the last 3 episodes of The Curbsiders to hear multiple pearls from the meeting (they’re not yet posted on their website, but available in the Apple podcast app).  But whatever you do, don’t let your new foray into Social Media interfere maintaining connections IRL with others or with getting a good 7.5 hours of sleep!

-Rob Nardino

Journey to Medical School

Thank you to Francine Zeng, student member from University of Connecticut, for this post!

Some people think that medical school ultimately shapes the type of doctor you are going to be and this is definitely true…to an extent. As a first year medical student at the University of Connecticut School of Medicine who is almost done with her first block, I can honestly say I have learned an immense amount of information. This ranges from learning all of the steps in a Core Physical Exam to the mechanisms behind several types of anemia that I had never even heard of prior. At the end of these four years, I am going to be able to reflect on all of the amazing experiences and all of the amazing people that have shaped me into becoming a physician and helped me choose my specialty. However, as I get further into medical school, I must not forget what brought me here in the first place.

I am blessed to belong to such a diverse class, filled with people from different backgrounds and at different points in life in general. However, all medical students have at least two factors in common and I will share them, along with my related experiences that have ultimately made me into who I am today.

1. All medical students are innately competitive, but truly mean well. We would not be in medical school if we did not put countless hours into achieving high grades, volunteering, conducting research, studying for the MCAT, and so on. The month before my MCAT, I recall waking up at 6 am to study, going to work from 9-6 then coming home and studying until 10pm before going to bed then repeating it all the next day. During my senior year of college, I poured hours of my final weeks into organizing the hospital volunteer group at UConn and stayed up writing and re-writing my Honors thesis. I am not a lone example as the majority of my classmates were in a similar boat. However, the reason for our questionably insane work ethic is not the mindset that we must be better than everyone else, rather we just want to be our own best selves. My class is full of excellent students in their capacity to learn, as well as their willingness to help each other and support one another. Great physicians not only recognize their own potential, but also the potential in everyone else around them. This applies to patients and other physicians, and our main goal is to help everyone reach this potential so they can be their best selves too.
2. We would be nowhere without some form of support system. One of the most important questions to ask while conducting a patient history is whether the patient has support in their life, and this can be in the form of many things including: family, friends, religion, etc. I would not be here without the love and support of my parents, who encouraged me to work for my dreams ever since I was young. My four younger siblings motivate me to be a role model and to be a big sister they can always be proud of. My friends always provide comic relief when I am stressed out of my mind and always pull me back to reality whenever I get lost in life’s convenient challenges. I am also lucky to have had all of the amazing educators and faculty members, such as Dr. Rebecca Andrews, that have helped me find my passion in healthcare by educating me about the realities of becoming a physician. Regardless of the journey we take, we cannot always pick and choose the hardships that life throws our way, but we can pick the people we surround ourselves with to get us through them.

I could write pages about the entire journey that brought me to UConn Health, but the important reality is that I made it. There were plenty of times in undergrad where I questioned whether everything I was doing was worth it. In fact, I had experienced those same feelings during orientation as I learned about how remarkable my classmates are and even now, as the stress of our first exam is beginning to envelop us. However, every time I put my white coat and stethoscope, identify a new structure in human anatomy lab, and participate in active conversation with my peers and educators, I remember that I deserve to be here. With the support of those around me, I pushed myself to seize every opportunity to make myself a strong applicant and can still remember the feeling of pride and relief when I got my “UConn School of Medicine Acceptance” e-mail. I am extremely lucky to have had the amazing opportunities that have shaped me into the first year medical student I am today and I believe that I am truly a better person because of it. I am proud of who I am entering medical school, and I cannot wait to see how I emerge after these next four years.

Enhancing Our Well-Being

By now, this is not news to you: burnout among physicians is common. A 2017 Medscape survey indicated that 55% of internists experienced burnout, defined in this context as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.  ACP recognizes burnout as a significant threat and in response has developed an initiative to enhance physician well-being and professional satisfaction. In their statement of commitment, the College talks about “identifying strategies and necessary infrastructure to improve the efficiency of practice, reduce administrative burden, promote an organizational culture of wellness and enhance individual resilience.”  In her recent column on the topic, Susan Thompson Hingle, MD, MACP, Chair of the ACP Board of Regents, writes: “ACP has long identified reducing administrative complexities or burdens as a priority, and the Patients Before Paperwork Initiative addresses systems challenges and seeks to reinvigorate the patient-physician relationship by challenging unnecessary practice tasks.”  This is one step towards addressing dissatisfaction with the weight of administrative burdens.  Regarding organizational culture, ACP offers “Top 10 Culture Change Interventions to Reduce Burnout and Improve Physician Well-being”, including identifying a wellness champion, focusing on leadership development, and establishing a culture that emphasizes teamwork and relationships; I highly recommend reviewing this.

Many of us have teaching and leadership roles.  At the residency level, the ACGME also recognizes a need for change; they updated the common program requirements in response.  In this context, they relate self-care to professionalism and describe it as a skill to be learned and developed along with other aspects of residency training. Promoting resilience is an important part of the approach to reducing burnout, particularly among trainees and junior colleagues. In a recent commentary in Academic Medicine, Abaza and Nelson speak to the issue of role modeling and resilience: “More than just being understanding and supportive of our learners’ self-care needs, this means providing the role modeling they need to see to understand the relevance of self-care. […] We need to openly talk about the dilemmas we face in making choices between our needs, our family’s needs, and our patients’ needs. […] Balance does not mean forgoing responsibility for obligations but finding ways, to the best of one’s ability that day, to accomplish them within a reasonable framework.” [Acad Med. 2018;93:157–158.]

The solutions aren’t easy, but there is no question we need to continue to focus attention on burnout and resilience for the good of our patients and our profession. I urge you to review ACP’s resources at https://www.acponline.org/practice-resources/physician-well-being-and-professional-satisfaction.

-Rob Nardino, MD, FACP