Doctors Reject Ron Klain as Ebola Czar

Ron Klain poll, doctors and Ebola Czar

click to enlarge, credit: Whitehouse.gov

Ron Klain, the newly appointed Ebola Czar, has come under harsh criticism from physicians for having no prior healthcare experience. Klain, formerly was Chief of Staff to Joe Biden and Al Gore and is known as a Washington insider. He is a lawyer with no formal medical training.

We asked our doctors, “Do you approve of the newly appointed Ebola Czar, Ron Klain?” The response was overwhelming:

  • 79 % No
  • 21% Yes

What Doctors Think of the Ebola Czar

A few physicians were willing to take a wait and see approach. One Physiatrist wrote, “There are few physicians qualified or competent to run a major government task force. He is running an organization, not making medical decisions. The team will likely contain qualified scientists and physicians as well as on-the-ground experienced people. I would reserve judgment until we see the team assembled, and the responses developed and implemented. Right now, it’s all just knee jerk reactions.”

For more about Ebola protocols, click here.

One ophthalmologist reflected the majority opinion. He wrote, “Something is terribly wrong when the Czar is obviously chosen on the basis of who is most likely to contain the political fallout, rather than who has the most expertise in containment of bio-hazard. The Czar should specialize in bio-terrorism and bio-warfare. This should be obvious to anyone who understands the medical, environmental, and healthcare systems hazards.”

Do We Need an Ebola Czar

Many physicians questioned why we needed another administrative position to execute on Ebola matters. One Family Practitioner asked about Nicole Lurie, MD, MPH, who is the Assistant Secretary for Preparedness and Response (ASPR) for the Department of Health and Human Services.

From the HHS website, “The ASPR serves as the Secretary’s principal advisor on matters related to bioterrorism and other public health emergencies. The ASPR also coordinates interagency activities between HHS, other Federal departments, agencies, and offices, and State and local officials responsible for emergency preparedness and the protection of the civilian population from acts of bioterrorism and other public health emergencies. The mission of the office is to lead the nation in preventing, responding to and recovering from the adverse health effects of public health emergencies and disasters.”

As a physician, what do you think about the new Ebola Czar? What attributes should a candidate have? We discuss Ebola thoroughly on our new Infectious Disease Hub, if you’re an M.D. or D.O., please join us.

Why Ebola Preparedness Is So Haphazard

Ebola preparedness

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Ebola news scrolls by on our screens fast and furious.  A suspect case here, a hospital failing there, airborne rumors, social chatter with scary and conflicting information.  There seems to be precious little information coming out of official government channels.

Twenty-six Ebola outbreaks have occurred since 1976.  Researchers and medical teams documenting information about containment, contact lists, and patient care.  This outbreak, the first to touch an urban area, has screamed out of control debilitating nations as the death count relentlessly mounts.    The World Health Organization predicts up to 10,000 cases a week and in a best case scenario two months before the virus is back under control.

Extensive information about containment exists.  Ebola protocols have been around for decades and have improved as we learn from each outbreak.  Why then are so many mistakes happening now that Ebola has reached the United States?

Ebola Mistakes

Many within the community spoke about the Keystone Cops calamity that seems to be out there.  A list of mishaps include:

  • Releasing the first patient for two days into the community before transporting him by ambulance for hospitalization.
  • Hospital staff wearing light protection in the early days of Duncan’s treatment; now two nurses have contracted Ebola, and the contact list reaches 76 people.
  • A nurse with a fever and Ebola patient contact calls the CDC about her low-grade fever and is cleared to fly; now 132 passengers and airline staff are on another watch list.
  • Dr. Nancy Snyderman, after being potentially exposed to Ebola when her cameraman contracted the disease, “elopes” on voluntary quarantine for Chinese food.  Her “sorry, not sorry” response was she was asymptomatic and therefore not a threat.

Our most recent Ebola posts here.

We are also hearing from the physicians on the front-lines that they have received little, if any training.

One ER physician wrote, “As an ED physician, I have received no Ebola preparedness training. Neither has any other ED doctor or any of our ED nursing staff. We have NO IDEA if we have any personal protective gear or any protocol in place. But I did read in our local paper that our hospital is telling the media we are prepared for Ebola. In fact, they are holding a press conference today to explain it to the public! What a farce.”

A second physician wrote, “As an ED physician at a county hospital, I have still had ZERO training from my hospital on how to screen or isolate a potential Ebola patient. We have had no drills. No meetings. We have no isolation protocols, no plan. We are not prepared. No one believes it will come here, or infect enough people to be a real threat to the U.S. The CDC has told them not to worry and that it is hard to get sick from Ebola. So they don’t worry.”

Medical Personnel Search Online for Answers

Our infographic looks at the disconnect between medical teams and the flow of information.  Physicians, are searching for best practices and are often turning to online sources.  As of today, approximately 60 percent of all conversations in the Sermo community are focused on Ebola.  Physicians are sharing stories about preparedness, patient treatment options, the possible Ebola vaccine and travel bans.

Doctors look to multiple channels for Ebola information.  Fifty-four percent of doctors say they are checking with the CDC regularly, and 52 percent they are getting clinical information from their peers in Sermo.  If you’re an M.D. or D.O. you can join the community to learn more about Ebola.

What do you think about Ebola preparedness in the United States?  Do you support strict measures such as a travel ban from hot zones?  Where do you get clinical information about Ebola?

Doctors Support Travel Ban from West Africa

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In recent polling, a full 75 percent of physicians favor a travel ban from West Africa until the Ebola outbreak is better controlled.

The Sermo Physician Poll asked, “Do you believe all travel from West Africa should be halted to the US?”

  • 75% Yes
  • 25% No

With a total of 1,312 votes taken from October 3rd through October 10th, 2014.

Stopping Travel from West Africa

While 75 percent of physicians supported the ban, many wanted an exception for humanitarian aid. James Wilson, MD, Vice President of Ascel Bio and an infectious disease forecaster said, “We still need to get supplies, medical aid, and health care workers into the hot zones to help prevent the spread of the disease. We need to treat the people who need it most to prevent the virus from going global.”

Wilson also noted travelers from West Africa are actively traveling to South America, and trying to enter the U.S. from the South. “Ascel Bio has received several reports of West Africans arriving in South America.  There is now a suspect case of Ebola in Brazil.  The Department of Homeland Security’s Customs and Border Patrol have claimed they intercept illegal immigrants from West Africa, who attempt to enter the United States via the southern states.  The prospect of a surprise translocation of Ebola becomes far more complicated when examining these data points.”

One vascular surgeon who supports a travel ban wrote, “What we know for sure is the current screening methods used before leaving West Africa (questionnaires and temperature checks) don’t work all the time. That’s been proven in Dallas. Here’s an instance where preventative measures can make a huge difference in limiting the spread of this virus.”

A physiatrist expressed a common concern about travel and the movement of people who feel threatened if a ban comes to fruition. He wrote:

“The problem with banning travel from a specific location is it creates fear and desperation in the people from that area, causing them to find alternate ways to get wherever they wanted to go. But now they have to hide where they came from, making epidemiological efforts difficult or impossible if they do get sick. It’s not very hard to find an alternate travel route, and the more circuitous the route, the more potential exposures along the way. We just need to take this opportunity to learn to deal with this type of problem. More examples are inevitable as global travel is only going to increase.”

Ebola Preparedness In the US

The same poll asked physicians about preparedness in the US after the Dallas patient. The question asked:

Do you believe the experience of Dallas will significantly alter our medical preparedness writ large in America?

  • 56% Yes
  • 44% No

Physicians discuss preparedness training in detail on the Sermo Infectious Disease Hub. Our doctors share information from their local officials and also discuss best practices on site among dozens of infectious disease experts. There are many things to consider including contacts in the community, proper isolation of suspected Ebola patients and even the handling of testing equipment.

Wilson wrote about the testing equipment in Dallas, “There was a comment in the reporting on the recently deceased Ebola patient that on his first visit his blood was drawn, and routine labs were performed.  Implying, samples were sent back for routine processing in the main laboratory for CBC and chemistries.

Beyond the obvious concern of unnecessary exposure of the phlebotomist and laboratory staff, along with infection control considerations during sample prep, the key question was how the automated machines handled the specimen… with a specific eye towards inadvertent aerosolization of the specimen.”

As a physician, have you had Ebola preparedness training? Are there other infectious diseases that you are worried about such as EV-D68? If you’d like to discuss this more you can join the Sermo community, and join the conversation.

Ebola Infects Health Care Worker, Now 2nd US Victim

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A nurse at Texas Health Presbyterian in Dallas, TX who cared for Thomas Eric Duncan has contracted Ebola according to local health officials.

The unidentified nurse had an “inadvertent breakdown of protocol.”  While the press isn’t giving details on the new patient, members within the Sermo community are saying it was a female nurse, and the infection occurred on his second visit when he entered his final hospitalization.

James Wilson, MD Vice President of Ascel Bio and an infectious disease forecaster wrote, “Finally, at Day 17, we have a 2nd case of Ebola in Dallas.  The individual was a healthcare worker who was reportedly wearing “full” PPE but not identified as “high risk” on CDC’s contact list.  Now we have reports (as expected) that the individual may have breached protocol.”

A surgeon within Sermo wrote, “I can easily imagine how someone could breach the CDC protocol.  They don’t shed the protective gear by themselves, so it well could have been a colleague that caused the breach.”

An internist, referring to preparedness training said, “technique, technique, technique!  Practice, practice, practice and use the Buddy System.”

You can read more about Ebola preparedness training on one of our earlier posts.

Wilson goes on to make a few points about the new patient.

  • Out of all the cases on the contact list, note it was someone who dealt with the original case while he was maximally infectious and expelling infectious fluids.
  • You can wear all the PPE protection in the world and still contract an infection if you fail to observe proper protocol for removal of your gear.
  • We should have seen far more cases if this heavily mutated Zaire strain was in fact, as some have claimed, a highly efficiently transmitted (read:  airborne) agent.  But we have not.  It is impressive that none of the family members have exhibited symptoms yet.  Again, the majority of cases incubate within the 7 – 10 day window of exposure.

The Ebola outbreak is being discussed thoroughly on our Infectious Disease Hub.  If you’re an M.D. or D.O. please join us as we discuss preparedness training and tracking contact lists.

Mammography: To See or Not To See

mammogram

~ by Dennis Morgan, MD, Oncologist

There has been much controversy in recent years over just who should get screening mammography. The greatest contention is over what age to begin and how often to perform. Women will understandably bring a certain amount of emotion to the table. Ideally the medical community would bring curated facts to the table that inform a process of shared decision making. The major challenge for all parties involved is the curation process — not just knowing the facts, but making sense of them.

My overview of this subject comes at the behest of someone who recently underwent a harrowing encounter with mammography. As a medical oncologist my perspective is not necessarily neutral as I have an inherent wariness of the “slippery slope” of investigation and intervention that can lead to unintended, sometimes harmful, consequences. But I have no related service to promote or academic position to defend. Let me share my investigation of this controversy and invite comment.

Our first task is to separate fact from opinion. Opinion comes from personal values or professional goals. I would categorize the relevant literature into studies, reports and positions. Studies are original scientific investigations (facts), reports a critical analysis of such studies (interpretation of facts), and positions, i.e. opinions, about next steps. The landscape is dotted with any number of each. The area of hottest contention is the appropriate age bracket for screening. The value of any screening tool depends on the prevalence of the disease. In our case it is relevant the risk is proportional to age. Young women are  unlikely to have breast cancer, and the oldest women are more prone to getting it but also more often die of another condition. So the firestorm is over which of the ‘middle-aged’ women to screen.

Let’s take as our focal point the era before the publication in 2009 of the — infamous to some — U.S. Preventive Services Task Force (USPSTF) Recommendation Statement(1). This update of a 2002 paper is controversial for it’s radical departure from common practice. While supporting mammography for women age 50-74 it advised only a two-year, not annual, schedule. For women younger and older than this the task force was not persuaded of demonstrated benefit. Nor was any confidence expressed for the alternative imaging methods of digital mammography or MRI. Perhaps most shocking was their position that breast self-exam (BSE) is a waste of time and should not even be taught.

The blow back was swift and vehement, notably by The American Cancer Society (ACS) which maintains to this day that “Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s.” Further, “Mammograms should be continued regardless of a woman’s age, as long as she does not have serious, chronic health problems … ”. (2).

And this from a letter in the New York Times by the chairwoman of the Breast Imaging Commission of the American College of Radiology and the president of the Society of Breast Imaging (3):

“Every medical organization experienced in breast cancer (including the American Cancer Society, American Congress of Obstetricians and Gynecologists, American College of Radiology, Society of Breast Imaging and National Accreditation Program for Breast Centers) recommends annual mammograms for women ages 40 and older.”

I think it is notable that every organization cited is either positioned as a patient advocate/protector or is a provider of the service. Perhaps neither would be inclined to retreat from a posture of vigilance.

Their letter was in response to an op-ed piece (4) by a co-author of Quantifying the Benefits and Harms of Screening Mammography — an MD, MPH faculty member of the Institute for Health Policy and Clinical Practice at Dartmouth(5). He cited data from the radiology community itself that the false positive rate for over ten years of annual screening is 50 percent.  He noted, “A screening program that falsely alarms about half the population is outrageous.” and “What about the benefit? Among those thousand women, 3.2 to 0.3 will avoid a breast-cancer death. If you don’t like decimals, call it 3 to 0.”. His paper is, I believe, the most comprehensive and impartial survey to date and is discussed in his interview in the ASCO Post(6).

There is a growing list of studies and reports that recommend a decrease in the use of mammography but the message seems as foreign to the American institutions cited above as the countries originating them.

From Scandinavia 2008 in the Cochrane Database of Systematic Reviews — the Nordic Cochrane report(7):

“If we assume that screening reduces breast cancer mortality by 15% after 13 years of follow-up and that over-diagnosis and over-treatment is at 30%, it means that for every 2,000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings.”

From Norway 2010 in the New England Journal — The Norwegian Breast Cancer Screening Program(8):

“The difference in the reduction in mortality between the current and historical groups that could be attributed to screening alone was 2.4 deaths per 100,000 person-years, or a third of the total reduction of 7.2 deaths …”

From Canada 2014 in the British Medical Journal — 25 year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial(9). Annual mammography screening did not reduce long-term breast cancer mortality in women 40 to 59 years of age. An independent commentary on this study observed that “If the … results are correct, the number of “cured” drops to 0.” (10).

From Switzerland 2013 in the New England Journal of Medicine — Abolishing Mammography Screening Programs? A View from the Swiss Medical Board(11): Tasked with a recommendation for all of Switzerland the panel made several observations.

  1. Conventional recommendations are based on outdated trials that do not reflect the effect of modern treatment.
  2. It was not at all obvious that benefits outweigh risks when one compares a generally accepted 20% reduction in mortality with a 21.9% rate of over-diagnosis.
  3. They note women substantially overestimate the benefits. “It is easy to promote mammography screening if the majority of women believe  it prevents or reduces the risk of getting breast cancer and saves many lives through early detection of aggressive tumors. We would be in favor of mammography screening if these beliefs were valid. Unfortunately, they are not, and we believe that women need to be told so.” “The board, therefore, recommended that no new systematic mammography screening programs be introduced and that a time limit be placed on existing programs.”

Why such resistance to change given the benefits are less, and the risks more than previously appreciated? Evidence contrary to closely held beliefs is always hard to accept and confirmation bias, favoring reports that agree with an a priori position, is hard to avoid. In the case of mammography several forces marshal to stave off change. I would suggest that some combination of emotion, defensive medicine, lack of scientific understanding, and a profit motive are responsible for continued over-use of mammography in the US.

Let’s see if we can tie some of this together with a visit to the doctor’s office. The office staff advises the patient that she is due for screening mammography. Often accompanied by fear and hope the staff reinforces her decision by anecdotes about others whose ‘lives were saved’ by mammography. Her hope is that the result will be negative because she could then conclude that she does not have breast cancer. But this is not necessarily so. On the other hand if the mammogram is positive she would then think that while she does have breast cancer her life will be saved by this early detection. Again, neither of these assumptions are necessarily true.

There are four possible outcomes from mammography — a positive or negative reading, either of which may be true or false. These provide the data for Bayesian analysis that is the mathematical rationale for screening tests.

The false results are instructive as to why screening mammography may continue to be overused. With false positive results, further studies — additional imaging and biopsy — will, hopefully, declare the patient cancer-free after all. The patient is reassured, thankful for the vigilance of her physicians. Unnecessary treatment avoided.

With false negative mammograms the cancer may eventually surface by some other means and, when it does, everyone will have a second look at that mammogram. Assuming it wasn’t read in error (not the same as ‘false negative’), the patient will be told that mammograms miss 20% of breast cancers.  They’ll tell her it was a “good thing she was doing BSE” or good thing that some serendipitous event lead to discovery. The fact that the mammogram in her case was of no value will probably be over-looked.

What’s worse? A breast cancer diagnosis within a year or two of a false negative mammogram or no mammogram at all? The patient is likely to have considerable negative feelings and second guess her physician’s value more than the mammograms. Negative feelings about physicians drives lawsuits. Doctors know this and often practice “defensive medicine” — better to get a test of questionable value than face negligence accusations, no matter how unwarranted.

Doctors often do not understand the limitations of screening tests. Bayesian analysis gives answers that are not intuitive for patients or physicians. Physicians routinely over-estimate the chance of cancer based on a positive mammogram. We are all prone to attaching more significance to relative changes than to absolute values as with the Norwegian study cited earlier. Are we to heed the one-third reduction or the absolute difference between 2.4 and 7.2 deaths per 100,000 person-years?

As to a profit motive, we need not necessarily find villains here. I will be quick to recognize the honest efforts of those who make a living fighting cancer. Physicians need not be greedy to cling to a profitable activity but rather just trying to keep the doors open in this era of diminishing reimbursement for physician services. However, we would be naive to dismiss the notion of a “medical-industrial complex” i.e. a socio-economic force that organically organizes to preserve profit as the primary, if not only, motive.

So we are left with a debate that has powerful advocates on both sides. The debate is not whether mammography has any value. It is rather whether we are willing to limit its use as a screening method when the harm exceeds the benefit. And the harm in this sense is both personal and societal. Each life saved comes at some cost of over-treatment death from treatment including fatal heart disease from radiation, secondary cancers and a chronic state of anxiety amongst middle-class women. By analogy, consider automobile speed limits and death rates in pedestrian-involved accidents. We could lower speed limits until the chance of a pedestrian fatality is practically zero. But at some point livelihoods and lives are lost due to the lack of efficient transportation for work and emergencies.

Hopefully, we will develop screening methods for breast cancer that are more sensitive and more specific. Until then, women and their doctors should share the decision about mammography in individual cases based on an open discussion of both sides of the ongoing controversy. We should avoid bad choices based on fear and hope alone but rather employ new information to gain the most benefit for the risk from mammography.

We are left to wonder what indeed are the best practices? Many of the issues are covered in the three-way debate in the New England Journal — screen at age 40, age 50 or not at all(12).  Dr. Welch notes in his New York Times op-ed article(4): “It has been more than 50 years since the last randomized trial of screening mammography in the United States. Now that treatment is so much better, how much benefit does screening provide? What we need is a clinical trial in the current treatment era.”

We should at least have the courage to test in this country the hypotheses posed by breast cancer screening.

Bio

Dennis Morgan MDDennis Morgan, MD is Assistant Clinical Professor University of Connecticut Health Center, Emeritus Staff Johnson Memorial Hospital and Medical Center Stafford CT and Past President Connecticut Oncology Association as well as Past Medical Director Phoenix Community Cancer Center, Enfield CT

References

  1. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. U.S. Preventive Services Task Force. Ann Intern Med. 2009;151(10):716-726.
  2. American Cancer Society recommendations for early breast cancer detection in women without breast symptoms. 2014.
  3.  Weighing The Value of Mammograms. Monsees B, Rebner M. The Opinion Pages. Letters. New York Times. Jan 2 2014.
  4. Breast Cancer Screening: What We Still Don’t Know. Welch HG. The Opinion Pages. New York Times. Dec 29 2013.
  5. Quantifying the Benefits and Harms of Screening Mammograph. Welch HG, Passow HJ. JAMA Intern Med. 2014;174(3):448-454
  6. Confronting Uncertainty About the Harms and Benefits of Screening Mammography. Bath C. ASCO Post. Feb 15 2014, Volume 5, Issue 3.
  7. Screening for breast cancer with mammography (Review). Gøtzsche PC, Jørgensen KJ. The Cochrane Library 2013, Issue 6.
  8. Effect of Screening Mammography on Breast-Cancer Mortality in Norway. Klager M et al. N Engl J Med 2010; 363:1203-1210. Sep 23 2010.
  9. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. Miller AB. BMJ 2014;348:g366.
  10. Annual mammography screening did not reduce long-term breast cancer mortality in women 40 to 59 years of ag. Fletcher SW. ACP Journal Club | Volume 160 • Number 10. May 20 2014
  11. Abolishing Mammography Screening Programs? A View from the Swiss Medical Board. Biller-Andorno N, M.D., Ph.D., Jüni P, M.D. N Engl J Med 2014; 370:1965-1967. May 22 2014.
  12. Mammography Screening for Breast Cancer. Clinical Decisions. N Engl J Med 2012; 367:e31. Nov 22 2012.