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Armchair Clinicians, Welcome to Medicine

I am writing this article to welcome our new-to-the-profession audience who have over the duration of the pandemic become clinicians. I wanted to give you a warm welcome and break down the medical profession for you so you can feel more prepared for what lies ahead.

I know most of you self-taught clinicians haven’t had a chance to really mingle with the rest of us but we’ve just been busy with a few things. There was the opioid crisis where we apparently gave out too many opioids to patients and many died because of it. That was tough for everyone.

And then we were in this battle with MOC’s for board certification which has been and continues to be a time drain. On top of all that we got hit with the pandemic – which brings us to the present moment and welcome all new vaccine and virology experts.

As more people are participating in the clinical discussion when it comes to the pandemic it’s getting harder to delineate who is a vetted expert and who is an armchair clinician.

I first came across this new cohort of clinicians when I answered medical questions in patient forums. These are places where patients can ask medical questions and get replies from real physicians. This is often a free service and helps those who cannot afford medical care or just have questions that weren’t addressed during their clinical visits.

However, in this space non-clinicians have a tough time holding back from offering medical advice. The real advice coming from us gets therefore diluted which was the reason for this little article.

Offering Medical Advice

I don’t see anything wrong with offering medical advice online, whether by vetted clinicians or the layperson, or the self-minted MD. Most online forums will attach a “physician” label to those profiles who have legitimate degrees. They aren’t trying to discriminate against those who couldn’t obtain official training, it’s just that incorrect advice seems to have some bad outcomes.

Someone, for example, asks online what they should do about sudden onset unilateral blurred vision with floaters. The advice here is that you probably have to get seen urgently by someone who can assess you for all sorts of differentials such as a cerebral lesion, optic nerve disease, retinal damage, anterior chamber issues, and vascular issues.

A layperson will come on and advise that this patient immediately contact a retinal specialist. Which perhaps this patient might actually have access to, though that’s doubtful. This might delay their care since this kind of specialist may not see patients urgently or emergently unless they have been consulted.

The intention of this unofficial clinician is good but is clinically majorly flawed because this person doesn’t understand the healthcare system. They don’t appreciate the fact that if you only think of a retinal issue and wait to hear back from a retinal specialist you might miss a serious vascular lesion in the brain.

I would argue that we as clinicians have even forgotten how hard it is to be a clinician in real practice. The number of things we factor in and account for is truly astounding. Hold on, let me pat myself on the back for a second.

Hello, COVID-19

Let’s break down a viral infection that can cause a pandemic and has major health consequences for a subset of the population. This isn’t diabetes or cancer or hypertension but there are a lot of overlapping factors.

In order to deal with a pandemic we have to account for:

  1. clinical care
  2. public health
  3. political support

I listed it in that order for reasons which might become more clear in a minute.

1. Clinical

The clinical portion has to do with discussing treatment options while taking into account the short-term and long-term effects.

As a clinician, we also consider how the treatment of one patient group might affect another. If I tie up an entire hospital for just one disease type then I would have to tell another disease group that they cannot get care.

Clinicians – like MD’s, DO’s, NP’s, and PA’s – are good at triaging and with some support can decide whom to treat and whom to exclude.

Then there is the prevention part. We need some clean data from public health organizations to know what to recommend to patients. We might recommend masks to some groups, vaccination to another, and/or isolation to another.

The reason we would make these decisions is for obvious reasons; the patient is looking towards clinical experts for advice. If they see the advice coming from non-clinical organizations the message can quickly break down either due to politicization, propaganda, or poor communication.

2. Public Health

Public health works closely with political agencies to recommend actions which the population can follow in order to manage the at-large risk to the majority of individuals.

Public health doesn’t make individual decisions. They don’t factor in all variables, examine the patient, and come up with a custom intervention plan. They are more macro while we are macro.

Public health has to remain as neutral as possible without any political influence and work closely with the clinicians. If the voice of public health officials and clinicians are the same there likely won’t be much doubt in what steps to take next.

The way this is built out of course isn’t overnight. Public health has to build such relationships with clinicians over decades and then cash in that check when a pandemic occurs.

3. Political Intervention

If the clinicians and public health experts believe that something grand has to happen in order to prevent the spread of a disease that’s when politicians can step in and make it happen.

Some things aren’t feasible and other things are easier to manage. It’s not a left versus right issue at this point. The experts will always remain the clinicians and the public health officials.

At no point would it make sense for a clinician to tell a politician how to ratify legislation in the house because we wouldn’t know what we’re talking about. In the same fashion, no politician should be talking about the epidemic on clinical terms for the same lack of expertise.

Okay. So we covered the leading parties here and obviously I have left many entities out which are critical for an action plan to be successful.

The Keyboard Clinician

So back to our new audience of self-elected healthcare experts, clinicians, virologists, and intensivists. There are a lot of you who, after watching the news and reading NY Times articles and some research studies, have decided that they understand healthcare enough to want to throw your clinical opinion into the hat.

But it’s not just unbiased input you want to offer. You have rather strong opinions about how healthcare should be delivered and how patients should be treated.

I mean, you sort of vacillating a little too much. You jump around from being a clinician to being a public health expert to being a virologist researcher. Don’t worry, I’ll help you focus a bit when it comes to your self-elected profession.

By my observation, you have very little tolerance for people who oppose vaccination or continue to live unhealthy lives. You condemn anyone too easily who refuses to wear a mask or continues to smoke. These aren’t the best characteristics to emulate in your newly discovered online profession.

So let’s point to the gorilla in the room. Because vetted clinicians are now competing with you newcomers for disseminating clinical facts it’s created a touch of friction. I won’t lie, I’ve had to spend more time with each of my patients but I’m not mad at you. I just want to help you be … well, me.

The vetted clinician who has been working with a single patient for 15 years to get him to lose weight, be more active, control his stress, and use his medications the proper way is suddenly no longer the expert when it comes to convincing Jane Public to be on board with prevention efforts.

The Clinical Jargon

Everyone loves jargon. Surface proteins, mRNA vaccines, remdesivir.

But we don’t talk about this stuff with the same excitement and passion as the layperson. As vetted clinicians, we discuss prevention, treatment, and emergency intervention. And we consider each of these on an individual level based on many variables, unique to each patient.

We consider the patient, their risk factors, their exposure potential, their reluctance, education level, cost issues, and potential outcomes. Not much sense in making the discussion all about the jargon when it’s a tiny part of the equation.

We aren’t as excited by prone ventilation and standard PEEP values or medication hype on the news. After all, we speak the language of medicine. We’re fluent in this second language and our vocabulary and understanding are much deeper than what the clinical jargon will convey to someone at first glance.

So, I painted a good background for you, and now let me tell you how to be a clinician since you are trying to be one online and maybe in person one day? Pays really well. But you’ll be blamed for high healthcare costs, poor outcomes, long waits in the ER, botched surgeries, and the occasional opioid epidemic – or pandemic, not sure where that one falls yet.

1. Gain the Patient’s Trust

This is #1 because if the patient doesn’t trust you they won’t care what you have to say nor will they follow through.

To gain the patient’s trust you have to approach them in an unbiased manner and get to know them. Asking open-ended questions here is important. Knowing which questions to ask to which patient is the 6th sense you get after seeing a few thousand patients.

You’ll know you gained their trust because they are now sharing their fears with you and aren’t making eye contact with you to see if you approve or disapprove.

2. Read up on the Research

I’m not talking about a summary of a research article on Bloomberg or CNN. I’m talking about accessing the actual research study and reading the pertinent parts, not just the abstract.

Then you have to discuss it with colleagues and decide whether the suggested intervention is realistic. Sure, maybe azithromycin together with remdesivir will prevent 10% fewer deaths but if it clogs up 90% of all beds in all hospitals you lost the battle before you started.

Being the keyboard clinician you are you’ll have access to lots of these documents. But be ready to sit there late into the night and read through some boring stuff instead of spending time with your family or watching Family Guy.

Even if you have Wiki open on another tab you’ll have to reference some old medical school books to understand what the IL-6 pathway was about. I recommend findings these books on eBay or Amazon.

3. Filter out the Noise

Hopefully, you live in a society where clinicians and public health, and politicians are working together on the same mission when dealing with a pandemic.

However, if you don’t live on that particular planet you’ll have to try your best to stay away from any sources other than strictly clinical sources. Why? Because you’re human, dude. You’re just as easily influenced as a non-armchair-clinician.

What’s hype, what’s a fact, what’s still too early to make a decision on, and what will actually move your patients in the right direction.

4. Don’t Broadcast Your own Biases

Your patients don’t care if you’re Muslim or vegan. They don’t care if you are healthy as an ox, have six-pack abs, or have cracked the health nut. Patients have their own hurdles to overcome and you need to be in tune with that.

Perhaps you don’t believe that the data is strong enough to warrant a vaccine for yourself. Or maybe you just saw your own mother suffer in the hospital and die a tragic death from not getting vaccinated. Unfortunately, none of that will matter.

Your job as a clinician is to approach each patient as unbiased as possible. I mean, you’ll still be biased but less so. And you’ll have a much higher chance of success.

5. Ask Questions and Offer Answers

Ask a lot of questions, that’s how someone believes that you care. I’m am not talking about the passive-aggressive questions which might seem really clever online but instead, ask real questions that require introspection.

And when your patient gets short with you don’t take it personally. You’re in the inquiry phase. Your patient doesn’t know why you’re asking a particular question and might assume the worst.

Next, offer answers based on what you know. Are you just parroting back what you read on CNN? That might not be enough to win the patient’s trust.

If your patient wants you to explain to them how the inflammatory pathway works when the body is infected with the virus then offer them an explanation and let them take you down whatever rabbit hole they want. They are just trying to see if you’re for real or if you just have boilerplate answers.

6. Empower Your Patients

Your patient knows that nobody can force them to get vaccinated. But they don’t know if you respect this autonomy. So now you need to help your patient feel prepared and educated to make their own health decision.

Fortunately, your Hippocratic oath (oh, right, read up on that, you’ll need to take that) doesn’t dictate that you have to convince a patient either way. You’re there to be their shepherd on their health journey.

No matter what your own political or personal agenda, empowering the patient is all about helping them overcome their hurdles so that they can make the best healthcare decision for themselves.

7. Share Example Patient Experiences

You just took care of Mr. Smith who got vaccinated and maybe now he’s super fatigued. Or you had Mrs. Anderson who didn’t get vaccinated and now is recovering in a nursing home. You hopefully have many such anecdotes you can share with the patient.

This is going to be tough for you to do but perhaps you can use some personal stories. Fortunately, there are case reports as well. But sadly these reports aren’t as complete as you might expect.

Do your best here but your patient is going to care a lot about your actual experience with the disease

8. Address All Remaining Fears

So now you broke things down for the patient and you are sitting knee-to-knee or mic-to-mic with the patient. You guys have a bond and the patient knows you’re not about to push them into one decision over another.

What else is keeping them from feeling fully certain about their decision? Is there any doubt remaining? What fears do they have?

Believe me, this part is really hard. If you yourself, for example, are convinced that COVID-19 is a hoax, or that it’s not as serious as everyone says, or in fact the total opposite, how can you remain unbiased with this patient and continue to focus on the missing pieces of the puzzle for them?

Unlike me, you won’t be able to rely on your many years of having to convince a patient that PreEP is safe and insanely effective. You have successfully worked with your African American patients who needed monthly injections and helped them realize that you weren’t experimenting on them. And you have convinced 100’s of teenagers who were afraid to reveal to you that they are sexually active so that you could take better care of them.

9. Come up with an Action Plan

What further reading could the patient do? Where else can they look for support and further education? Are there people who are even more experienced than yourself that they could talk to?

If they choose to not get vaccinated how else can they keep themselves safe? After all, you wouldn’t want to abandon them just because they went against what your biases or beliefs are – remember your Hippocratic oath.

10. Circle Back

The patient decided for intervention A but not intervention B and they are convinced they are right. And you have data to show they are wrong. Be sure to remain on their good side and follow up with them in 5-7 days and ask if they have any follow-up questions.

Hopefully, you didn’t try to force something down their throat because if you have my experience you’ll know that your patient will only dig their heels in more.

Chances are they will have other questions. Answer them again and offer for them to come back into the office for further discussion.

Fortunately, you’ll have time for all of these discussions and further reading because you’re a physician. And since the consensus is that you’re overpaid and have all this extra time to go on fancy vacations and buy a fancy car, well, you can afford to put a little more effort into your patients.

Maintaining Your Sanity

Now, you’ve been spending a lot of time with patients and even more time studying up on this new disease. You have to take care of yourself. And there is more.

You’re naturally finding yourself excluded from real decisions in healthcare. You’re wondering if you are even a doctor. Some random Joe online has 5 million followers because he’s yelling something about the pandemic into his phone every few days from inside his car.

You’re also reading that people are thinking you are in on something shady. I guess that kind of makes sense because the politicians are putting out statements one day and backtracking the next and you don’t even know how to reach a public health person.

In fact, the only thing you know about public health is that if you don’t report a reportable condition to them you might lose your medical license.

On top of all this, you have your own health decisions to make and that of your family. And suddenly everyone around you is a healthcare expert so you find yourself at a socially distanced party where everyone except you is discussing the surface protein mutation.

If people around you aren’t healthcare experts yet they are certain on their path to becoming one. The rest are sending you tons of YouTube videos, articles, and asking your opinion on everything COVID-19 related. Son, you got your hands full.

Time to decompress and do some meditation. I would recommend listening to Eckhart Tolle or just doing some simple telemedicine work on Nurx. Nobody there is gonna ask you COVID-19 questions.

Anyway, if after reading this you still want to be a clinician, welcome. Excited to have you as my colleague and discuss clinical topics together. You can find me on Doximity, Figure1, Uptodate, and on a few Facebook physician groups. And hit me up and I can add you to some Whatsapp physician groups I’m in – really good clinical discussions going on there.

Pro or Against the Vaccine?!

I left you all hanging a bit, haven’t I? I know most are asking themselves whether Dr. Mo is pro-vaccine or against the vaccine. I mean you sort of have to lead with that these days before broaching any topic involving the pandemic.

The disappointing answer is that I have no allegiance. I don’t care if my patient gets the vaccine or doesn’t. I know that you might be thinking that I should be expelled from the medical profession for being so neutral. Lemme ‘splain.

Sincere neutrality is what sets a real clinician apart. The elite clinician doesn’t bother with politics. They don’t take sides because they don’t have to and it won’t change the health outcome of their patients.

Imagine going to your doctor who isn’t a fattist. They don’t care what or whom you sleep with. They are color blind and don’t care what you’re sporting in your undies.

I suppose by now I have painted a rather banal picture of medicine. It’s no Scrubs or House. And for us the combo of azithromycin, dexamethasone, and tocilizumab just isn’t all that exciting.

When this pandemic is handled we’ll have the seasonal flu to worry about. Then we’ll be dealing with Hep C screening. Obesity never takes a break and there is always depression, anxiety, insomnia, and poor diets.

If this profession isn’t for you, after all, no worries. Political discussions seem to need a lot of armchair politicians and there is always quarterbacking football. Jeff Beso’s personal life, net worth, and sexual orientation will also need further public discussion.

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