At my office and going around town, I see a lot of people wearing masks. A lot of confusion exists about whether and how to wear a mask. As someone who has worn surgical masks for over 40 years, I guess I have some authority to comment on this “new normal” (I hate that term!).
In normal use, surgical masks are supposed to protect the patient from bacterial contamination by the surgical team. Masks are only worn by patients when it is known they carry a highly communicable disease. In practice, mask wear is all over the place. I wear mine snugly, in part because, if I don’t, my glasses fog up. Anesthetists/anesthesiologists and nurses on the surgical wards are especially bad at mask wear. They wear them too loose, improperly tied, under versus over the nose, etc. Although I have worn masks for forty years, I don’t like them and take mine off as soon as I can.
The N95 mask that everyone talks about, because it is so effective in filtering out viruses, is awful. It is claustrophobic, stifling, and difficult to breathe through. I wore one in surgery, once. Never again. I also found that I could not understand people wearing these. Their words came out muffled. It made me concerned about what would happen in an emergency, when clear communication is crucial.
Dr. Mayo: “Mr. Smith, I am afraid I have some bad news.”
Smith: “Oh, no, doc. Is it about my blood tests?”
Dr. Mayo: “’Fraid so. Your blood test shows you have colon cancer.”
Smith (with trembling lips): “Doc, are you sure?”
Dr. Mayo: “Well, there is a 30% false positive rate.”
Smith (hopefully): “Gosh, doc. That’s good, right? It could be wrong. What happens now? Will you repeat the test?”
Dr. Mayo: “No. I have you scheduled for colon surgery.”
Smith (in disbelief): “But, doc. Why not repeat it first?”
Dr. Mayo: “Well, it won’t be any more accurate than the first one. And, besides, we just can’t go around repeating tests on everyone. There aren’t enough to go around, and they’re expensive. Hey, remember, you have a 70% chance that the test is right. Those are pretty good odds.”
Smith: “How can you expect me to do something this radical based on a 70% chance of being right?”
Dr. Mayo: “Hey, nothing in medicine is 100%.”
Smith: “I can’t believe this. You said I had no risk factors. I don’t have any symptoms. This was supposed to be just a screening. How will you know what part of my colon to remove?”
Dr. Mayo: “That’s just it. We don’t, so we’ll just have to take the whole thing out. Don’t worry, people live perfectly normal lives with colostomies.”
Smith: “No! Doc, this is crazy. I can’t turn my life upside down like this. I have a business, employees, a family. They depend on me.”
Dr. Mayo: “Mr. Smith, that is a very selfish, irresponsible attitude. I am only acting in your best interest. Think of all the people who will be negatively impacted if we don’t do this- the operating room nurses, the laboratory personnel, the pathologist, the hospital administrators, the housekeeping crew, and many others. Think of the ripple effect.”
Smith (sheepishly): “When you put it that way, doc, let’s do it!”
Dr. Mayo: “Great! Now, let’s look at your insurance coverage. By the way, do you have any friends who want to be screened for colon cancer?”
(Current tests for the SARS-CoV-2 virus are currently giving a 30% false positive results. Turnaround times for screening are as long as two weeks, which is about as long as most authorities allow that this valid to show someone might not be infectious. Someone needs to tell the virus it is not allowed to infect anyone during that two week window)
“Social distancing and shelter-in-place must end immediately, not tomorrow or next week.. Now. Not phased in. Fully and immediately.”
The discussion is endless and contentious. The questions are many, and and so are the answers. Has social distancing helped the cause in fighting SARS-Cov-19, hereafter referred to as CV-19 for simplicity? Does shelter-in-place work? When can we lift these restrictions? Should they be lifted right away or gradually and, if the latter, over what time frame? How many people have been infected? Do we develop immunity by being infected? How long does immunity last? What is the true death rate? The list of questions goes on.
There are some points of agreement even among those divided by a wide gulf of opinion. The virus came out of Wuhan, China and spread so rapidly because the Chinese communist government deliberately misled the WHO and the world; on this there is remarkable unanimity of agreement worldwide. It is as contagious, if not more so, than seasonal flu. It hits the respiratory system particularly severely. It is mild to asymptomatic in close to 100 percent of children and young adults, and over 95% of most adults under 60, with infection fatality rates falling almost daily. Even in the most vulnerable age group, those over 80 years, the case fatality rate (deaths among those who are actually ill) is a relatively low 15% at most. We do not yet know the most important number, the infection fatality rate (deaths among those who have been infected with the virus). This will tell us how bad CV-19 is compared to seasonal flu, the virus it is most often compared to in terms of danger.
This is a long post and I don’t want to make it longer than necessary. Dr. Williams is a family practitioner in Bessemer, AL. Below is his follow to his original post. You can find that post at: https://coronavirustruths.godaddysites.com/ . I encourage you to read this through. Do your own research. Make up your own mind. What we are doing does not make sense with this continued lockdown of our nation.
By David Williams, MD
On April 19, 2020 I authored a paper titled, “The Truth (and Lies) about Coronavirus.” It was revised to a final version on April 23. If you have not read it, it is readily available through a link from the Tide Wellness Facebook page or on Rock 103’s website in Memphis. If you read the original, please go back and read the revision and addendum.
I referenced coauthors in the original, but there are no coauthors on this paper. It is simply too personal. In almost 25 years of clinical practice I have treated thousands of patients with infectious diseases. I have worked in primary care, urgent care clinics, and emergency rooms. I have cared for the elderly and immunocompromised in nursing homes and at the VA. I have provided for the disadvantaged while supervising a rural health clinic. However, this could have been written by a journalist, football coach, or hairdresser and it would not affect the truth. If this becomes Dr. Williams vs Fauci vs CNN vs Trump no one wins. American citizens have historically been smart enough to reach their own conclusions without relying on what I say or anyone else says. We don’t have to live in a society that bases its belief system on what someone else says, what network they are on, or what party they are affiliated with. We are better than that. This doesn’t need to be a war between talking heads where people take sides. The fact this debate has been politicized and sensationalized is not helping us. In fact, that’s exactly why we are in this situation now. I am merely attempting to present the basic facts.
It is very easy to compare COVID-19 and influenza. Anyone can do that. It is easy to see how the number of deaths attributed to a disease can and will be impacted by directives to modify what goes on a death certificate. It doesn’t take a rocket scientist or immunologist to understand our current policies are leading to both a greater negative health impact than the virus ever will, but also an economic depression we shouldn’t have to face.
This is my imperfect attempt to put into words my current thoughts and feelings regarding this entire Covid-19 situation. Today, after more than five weeks of sheltering-in-place, social distancing, and being prohibited by the powers-that-be from practicing my profession, I thought I would be delighted at the welcome news that the governor has given the go ahead to resume elective surgery on May 4. Instead, I find myself angry and sick at heart. Having no better appropriate outlet for my anger- going into a quiet corner somewhere and shouting obscenities at nobody doesn’t seem productive- I am sitting here writing down some thoughts. I will go over this later and see if any of it is worth sharing otherwise it will never see the light of day.
I see a world I no longer recognize. It is a world in which there appears to be a deliberate campaign of disinformation and misinformation the purpose of which, more than anything else, seems to be to instill and maintain an atmosphere of unreasonable fear. The underlying purpose of this is still unclear. I think we have long passed the point where we can justify the current situation on the basis of public health. The American people have accepted almost without question a degree of government encroachment of their personal liberties which would have been impossible without the fear factor. We have permitted the Federal, state, and even local city governments to tell us we cannot leave our homes, we cannot keep our businesses open, and we cannot gather in other than tiny groups. A population of 300 million people has allowed itself to be quarantined and a trillion dollar economy has been shutdown, without a timetable or any inkling of the possible repercussions, for the first time in our history. All this because of fear. Fear of a virus about which we admittedly do not know everything, which is not to say that we do not know a lot about it.
It is stating the obvious to describe that many, if not most, of the population of the US are in a state of anxiety, some in fear, and a few even panicked regarding Covid-19. I think that much of this is due to a misunderstanding that we are defenseless against SARS-CoV-2, the virus that causes the illness we call Covid-19, and some still refer to by its place of origin, China. We are not and here is why.
It is critical to understand that we live in a world invisible to our senses that is teeming with bacteria, viruses, and fungi. Some of these are beneficial, in fact essential, to our health and well-being. Others are actually or potentially pathogenic (disease-causing). The fact that most of us do not succumb to these early in life is ample confirmation that we are not defenseless. The reason is our immune system.
The cells, organs, and processes that, in sum, make up are immune system are arguably the least understood aspect of the human body. The complexity is staggering. I will attempt a very basic explanation of how it works in the case of SARS-CoV-2. Hopefully, this will help to understand how you can protect yourself and reduce some of the fear this epidemic has created.
“The only thing we have to fear is fear itself.” Franklin D. Roosevelt
To be perfectly clear, I am not a virologist, epidemiologist, or public health expert. I am a plastic surgeon, i.e. a physician, with forty two years of practice experience and more than average knowledge of the human body than most people. I find myself dismayed at the abject state of panic, anxiety, and fear in the US today because of SARS-CoV-2, the official name of the virus that causes the respiratory illness Covid-19 and the reason for the current epidemic.
A recent article in Lake Healthy Living magazine (A Healthy Debate About Vaccines, September 2019) suggested that there is a debate about childhood vaccination. The article was, in my opinion, a well-intentioned but misguided effort that misrepresented the issue as a real debate. This is my response, as a physician, father, and grandfather.
If there is a sacred maxim in medicine, it is this, “Primum non nocere”. It means, “above all else, do no harm”. The reality is that doctors harm patients all the time. Not knowingly, not on purpose, and certainly not out of evil intent. It is an inescapable fact that the art and science of medicine are no more or less perfect than any other human endeavor.
A common thread throughout the course of human history had been the presence of illness and disease. Parallel to this has been the constant striving to relieve the suffering derived from these, beginning with the earliest healer or “medicine man” invoking the spirits he perceived and using those plants and animals available to him, progressing to the physician of today armed with the most advanced tools science can provide.
“Mohs, which stresses taking thin margins, has no place in treating invasive melanoma.”
It is a classic case of a hammer in search of a nail. Slow Mohs surgery for melanoma not only makes no sense, it is a bad idea that compromises treatment of this potentially deadly cancer.
While Mohs surgery still carries the name of its originator, Dr. Frederic Mohs, the technique has evolved from the 1930’s. Even so, the basic premise is the same. Now called Mohs Micrographic Surgery it is still the exclusive purview of Dermatology. The goal of Mohs is to remove skin cancers with clear margins and as little normal skin as possible. It is always done in an office setting. The skin cancer is removed under straight local anesthesia, the patient bandaged and sent out to a waiting room, and the surgeon examines the specimen to assess the margins. If they are clear, the patient returns to the surgery suite to have the site sutured or otherwise closed in some fashion. If the margins are not clear, the patient is brought back, more skin removed, and the process repeats until clear margins are obtained. Each excision stage takes around 45 minutes or so. With Mohs, the average skin cancer requires 1.7 excisions, which means that many require two or more excisions for clear margins.
Until fairly recently, Mohs was confined to non-melanoma skin cancers such as basal cell and squamous cell. These are typically confined to a small area of skin and are only extremely rarely life-threatening. While Mohs has a place in the treatment of skin cancer, I believe that it is sometimes used in situations where it is not the best option.
Recently, dermatologists have begun to perform something called “slow Mohs” for early melanoma cancer. Invasive melanoma cancer, even an early one, is a potentially life threatening condition. Excision is the primary treatment and wide excision, i.e. taking a wide margin of skin around the cancer, is the sine qua non of melanoma treatment. There is no place for taking close margins, even for the earliest, non-invasive melanoma, melanoma in situ. Mohs, which stresses taking thin margins, has no place in treating invasive melanoma. Even with very early, non-invasive melanoma in situ, the accepted standard is wide margins of no less than 5 mm.
The term “slow” Mohs reflects the fact that the process always takes more than one day. Processing a melanoma specimen takes 1-2 days. Therefore, the patient is sent home with their open wound bandaged and made to return a few days or up to a week later for either closure or yet another excision. One patient referred to me underwent three excisions over the course of three weeks! This is painful and distressing to patients and increases the risk of infection. There is no excuse for this. This is not the case with traditional wide excision.
I spoke to a dermatopathologist who processes a lot of slow Mohs specimens. She is not a fan of the procedure because of the way the specimen is taken and has to be processed. This makes it difficult, if not impossible, to establish the final margin, which is the closest the melanoma comes to the final surgical margin. Let me stress this: the goal of melanoma cancer excision is not to remove it with the smallest possible margin, which is the goal of slow Mohs. It is to remove the cancer with a generous margin, usually deemed to be 5 mm or more. Most slow Mohs excisions take only a 1-2 mm margin. This small difference can be the difference between curing the cancer and experiencing a recurrence, or worse.
Why the recent push for Mohs in treating a life threatening cancer? I believe that Mohs for melanoma reflects a misguided ordering of priorities. The first priority in treating melanoma is to cure the patient. The concern over reconstruction and the cosmetic result are important, but clearly secondary to that critical primary goal. In 1957 Drs. Harold Gillies and D. Ralph Millard, Jr., two of the pre-eminent plastic surgeons of the last century, wrote, “Too often, the general surgeon will ask courteously whether sparing such and such a bit will make the repair easier. He is genuinely trying to help in the repair and forgetting his primary duty. The answer must be, “I couldn’t care less. You remove the malignancy so it does not recur, whatever the deformity, and let me worry about the repair”.
Slow Mohs attempts to force a deadly cancer into the same treatment category as non-melanoma skin cancers, which are not life threatening. Ask any general or plastic surgeon what they think about slow Mohs and you will hear almost universal condemnation of the procedure. Even among dermatologists, slow Mohs is controversial. The bottom line is that it simply makes no sense. I would never allow myself or anyone I know to be treated for any melanoma using slow Mohs.
I went to see the new Downton Abbey movie reluctantly. My wife and her friends, all fans of the popular series, set up the evening for our group of five couples. None of the husbands were thrilled but we have all been married long enough to know that now and then you take one for the woman you love. Surprisingly, it was an excellent movie and very engaging (I am not just saying this because I know my wife might read this). There was even one moment of action involving a gun, so it wasn’t all tea and crumpets.
Downton Abbey provides a glimpse into life in a time where women were rather lightly regarded in society. What influence they had was largely in the background, exerting influence on the men in their lives, for example. Several female characters bemoaned their lack of stature, even among the aristocracy. This was not surprising, given the societal norms of the times. What was interesting, though, was the general theme of the movie previews. Two previews were for movies about female empowerment. One was a for a biopic about Harriet Tubman and the underground railroad. The other was about a movie adaptation of the book, Little Women. I am seeing this more and more and I do not think it is my imagination that the theme of women’s empowerment seems to be everywhere. From the U.S. women’s soccer team victory celebration to countless commercials on television, there is a continual thread about women overcoming victimization or societal obstacles to fulfilling their individual destinies. Either implicitly or explicitly, the cause is always male domination and subjugation of women.
What began as the #MeToo movement to address sexual violence and sexual harassment in the workplace has morphed into a general movement of women’s rights and empowerment. It is the women’s liberation movement for the age of the internet and social media. I am not a social scientist or scholar in such issues but I do have an interest in them. I am “privileged white male”. I have an office full of women, I am married to a woman, I have two daughters and a daughter-in-law, and three granddaughters. I try my best to be the best boss, husband, father, and grandfather that I can be. I can say the same for most of the men I know. I am all for women’s empowerment, rights, etc, but this emphasis on promoting this everywhere I look has bothered me and I am not sure why. So, I asked someone.
The person I chose is a close female friend who I know
retired relatively recently from a top level corporate job in a very
male-dominated engineering environment. I asked Susan what she thought of all
the recent media emphasis on women’s empowerment. Her answer surprised me.
Susan feels insulted and marginalized. She said that it is as though all of her decades of hard work, and that of her peers in the business/technical world to overcome male barriers to advancement and acceptance were for naught. Susan dealt with discrimination, sexual harassment, not being taken seriously, making less than her male peers for the same work, covering for less than competent male co-workers. She overcame those to become a senior executive. She said that, over the years, she saw major changes in the workplace such that she feels that, today, there are no real barriers to women being as successful as they choose to be and are willing to work for. She challenges the premise that there are male dominated, systematic, societal rules in play to hold women back.
I look at my own field of medicine. Today, women make up just over 50% of all medical students in the U.S. In the corporate world, the numbers are less impressive, with recent reports that only around 6% of CEO’s of Fortune 500 companies are women. Many explanations have been given, nearly all based, at least in part, on the premise of some form of gender discrimination. One different explanation, proffered by no less than Dr. Jordan Peterson, a clinical professor of psychology at the University of Toronto, boils down to this: women are not willing to be the disagreeable, aggressive type or make the sacrifices necessary to become a CEO at this elite level. He does not feel it reflects either female weakness or male privilege.
An interesting assessment of the #MeToo movement for general
female empowerment was provided by Heather MacDonald, an attorney and fellow at
the Manhattan Institute, an economic think tank. In her words:
#MeToo is going to unleash a new torrent
of gender and race quotas throughout the economy and culture, on the theory
that all disparities in employment and institutional representation are due to
harassment and bias. The resulting distortions of decision-making will be
largely invisible; we will usually not know of the superior candidates for a
job who were passed over in the drive for gender parity. But the net
consequence will be a loss of American competitiveness and scientific
She goes on:
“Pressures for so-called diversity, defined reductively by gonads and melanin, are of course nothing new…….however pervasive the diversity imperative was before, the #MeToo movement is going to make the previous three decades look like a golden age of meritocracy. No mainstream institution will hire, promote, or compensate without an exquisite calculation of gender and race ratios.”
The sordid Weinstein, Spacey, Epstein, and Lauer episodes that appear to have fueled the #MeToo movement are sad, sorry tales of abuse and victimization of women by serial abusers, but they are aberrations and not representative of men in general. To paint us with the same brush is unfair to all the men who have championed women and never victimized anyone. To further expand these isolated incidents of sexual harassment to represent the state of women in the workplace today is a stretch and unfair to women who persevered and changed the culture. It perpetuates that cult of victimization which, I feel, is definitely pervasive in the U.S. today and ignores all the work of women, like Susan, who came before.