Buried in my old blogs is a post where I wax on about my career in Rheumatology https://wordpress.com/post/theviewfromharbal.com/470. Even though I haven’t seen a patient for over 2 years, I still write for and publish in the medical literature about the things that held my passion. Way back in May I submitted my 4,066 words on “Arthroscopy in Rheumatology: Where have we been? Where might we go?” to Rheumatology (Oxford). Yes, that Oxford. My mentor Bill Arnold and good friend and number one ‘scopy buddy Ken Kalunian joined me as co-authors. To our surprise and delight, it was accepted July 31st after a few revisions. On December 1st, I received notice from Oxford University Press that it had at last been published, not between the covers of a journal yet, but electronically accessible. My copyright agreement with Oxford restricts how freely I can share the article, but I am allowed to post it on my website. So here it is. Worth at least a scan and the figures are pretty, I think.
Merry Christmas to all my friends and whomever happens to stumble on this site! It’s morning as I write this. No presents yet, not even breakfast. Kathy and I sit by the fire, excerpts from the Messiah playing, sipping our orange-juice free mimosas. The nature of the crisis at hand hit me early. Kathy and I have a shoe box full of our favorite Christmas CDs, which lives in the storage room till this wonderful time of year. Between Spotify, WRCJ and WFMT, most of our Christmas music needs have been met by our iTouch. We decided this morning to pull and play our favorites. We’d played a few here and there, but there were a lot we haven’t heard for a year. The pile got pretty big pretty fast and we realized there weren’t going to be enough hours in this day to play even a fraction of them, no matter how late we stayed up. What to do? The thought came, aren’t there 12 days of Christmas? Sure we all know the silly song with the French hens, turtle doves, five gold rings and all, but what about those 12 days? For most of us Americans, it’s back to work on the 26th and that’s that. Maybe a little bargain shopping and some lousy football with a hiccup for New Year’s, plus still a slowdown at the office, but the post-Christmas hangover wastes no time in arriving. Those of us church goers hear our pastors refer to the Sunday after New Year’s as “Epiphany”, but I’m not sure we emerge knowing what “an illuminating discovery, realization, or disclosure” we’d just experienced. But if we understand Epiphany, we might begin to understand the bookends of what was once a week and a half of festivities, not just the climax of Christmas we’ve come to accept. Epiphany marks the day the baby Jesus was visited by the Magi (the 3 Wise Men). Not that long ago, each day between Christmas and Epiphany was marked by a feast honoring a saint. Here it is explained (from https://www.whychristmas.com/customs/12daysofchristmas.shtml)
Day 2 (26th December also known as Boxing Day): St Stephen’s Day. He was the first Christian martyr (someone who dies for their faith). It’s also the day when the Christmas Carol ‘Good King Wenceslas‘ takes place.
Day 3 (27th December): St John the Apostle (One of Jesus’s Disciples and friends)
Day 5 (29th December): St Thomas Becket. He was Archbishop of Canterbury in the 12th century and was murdered on 29th December 1170 for challenging the King’s authority over the Church.
Day 6 (30th December): St Egwin of Worcester.
Day 7 (31st December): New Year’s Eve (known as Hogmanay in Scotland). Pope Sylvester I is traditionally celebrated on this day. He was one of the earliest popes (in the 4th Century). In many central and eastern European countries (including Austria, Bosnia and Herzegovina, Croatia, Czechia, Germany, Hungary, Israel, Italy, Luxembourg, Poland, Slovakia, Switzerland and Slovenia) New Year’s Eve is still sometimes called ‘Silvester’. In the UK, New Year’s Eve was a traditional day for ‘games’ and sporting competitions. Archery was a very popular sport and during the middle ages it was the law that it had to be practised by all men between ages 17-60 on Sunday after Church! This was so the King had lots of very good archers ready in case he need to go to war!
Day 9 (2nd January): St. Basil the Great and St. Gregory Nazianzen, two important 4th century Christians.
Day 10 (3rd January): Feast of the Holy Name of Jesus. This remembers when Jesus was officially ‘named’ in the Jewish Temple. It’s celebrated by different churches on a wide number of different dates!
Day 11 (4th January): St. Elizabeth Ann Seton, the first American saint, who lived in the 18th and 19th centuries. In the past it also celebrated the feast of Saint Simon Stylites (who lives on a small platform on the top of a pillar for 37 years!).
Day 12 (5th January also known as Epiphany Eve): St. John Neumann who was the first Bishop in American. He lived in the 19th century.
The eve of day 12 – Twelfth Night – is still a big deal in England. One big party. Poor and rich often change roles. Shakespeare titled a play about it. Practically speaking, it’s traditional to take your Christmas decorations down after 12th night. We leave ours up to Imbolc (Feb 2nd, a.k.a, Groundhog day https://wordpress.com/post/theviewfromharbal.com/163).
Some say early Christians appropriated this time of year to celebrate the birth of our Savior in order to co-opt the Pagans, who had a dandy celebration going at the time of the winter solstice called Yule (https://www.bbc.co.uk/religion/religions/paganism/holydays/year.shtml). I don’t know how long the Pagans went at it after Yule, but the Christians sure knew how to keep the party going! Falling away from the church means some spiritual losses to be sure, but look what else you’re missing! Kathy and I are looking forward to celebrating the next 12 days to the fullest, including playing all that Christmas music!
If somebody near you does that, should you be concerned? Sure, sick people expel the virus that’s making them sick through body fluids forcibly propelled outward. You can see a graphic demonstration of that phenomenon here https://www.youtube.com/watch?v=2mnC43QRsuM
I think most of us saw the brief video of one extreme response to something like this back at the beginning of the pandemic. But it’s worth seeing again https://www.youtube.com/watch?v=LawuQG8Z81w
But isn’t it the stealth asymptomatic carrier the one about which we’re all worried? Isn’t that what the masks are protecting us from, both ways (let’s not get into the chain link fence/mosquito deal; just remember the pores in that blue mask of yours are way bigger than the 100 nanometer virus). Might there be lessons to be learned from somewhere else? For example, do we still respect what comes out of China? They gave us this virus. They were also the first to handle the outbreak, and figured out quite a few things which we then followed https://wordpress.com/post/theviewfromharbal.com/337. So might they still be able to teach us something about it? A week before Thanksgiving, out of Wuhan, this time from Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (not the virology lab), came a study published in Nature Communication, one of premier journal Nature’s many versions, this dedicated to rapid communication of scientific findings. In the study – “Post-lockdown SARS-CoV-2 nucleic acid screening in nearly ten million residents of Wuhan, China” – they went out to survey everyone in Wuhan, with a population of more than 11 million people, more than our whole state of Michigan. They started about 6 weeks after the lockdown had been lifted which officials had placed on the city during the peak of the crisis. By then, the infections had largely burned out, only 6 new cases in the 4 weeks after. They got 92.9% (9,899,828) of the city to “participate”, with medical review and DNA test for the virus (test tube brush up the nose). They found not a single symptomatic new case. They did find 300 people who carried the virus but were not sick (no symptoms whatsoever). Then came the kicker. They assessed 1,174 close contacts of these “asymptomatic carriers”. And how many of them had the virus? ZERO. That’s right, as in zip, zilch, nada. You can read it for yourself here https://www.nature.com/articles/s41467-020-19802-w. * There’s more in the paper, of course, but mostly it details characteristics of the “asymptomatic carriers”.
If asymptomatic transmission of coronavirus is not happening, and it appears with scientific certainty it is not, then all of the current lock-down regulations, mask wearing requirements and social distancing rules/decrees are based on a complete fallacy of false assumptions. Our betters tell us to “respect the science”. Well?
Sundance cites a longer article from an economics journal that goes into depth about the fallacy of asymptomatic spread and the damage being done by measures dictated to protect us from something that is not happening https://www.aier.org/article/asymptomatic-spread-revisited/. I’m saving it for later, as I wanted to get out the Wuhan finding.
Let me close today with one more citation. I’m sure I’m not the only boomer getting ever more fed up with those taking away my liberties in the name of protecting me and others. A man once so popular and respected, his name followed by “…is God” was scrawled on the walls of the London venues where he played, has picked up his axe and lent his voice to an anthem for our times, penned by another revered boomer rocker. So here is Eric Clapton singing Van Morrison’s “Stand and Deliver” https://www.youtube.com/watch?v=tMkV4vYr_ik. The words are simple and true, and I’m sure you’ll be able to sing along the second time through. It’s already been banned by Amazon and Spotify.
*Cao, S., Gan, Y., Wang, C. et al. Post-lockdown SARS-CoV-2 nucleic acid screening in nearly ten million residents of Wuhan, China. Nat Commun11, 5917 (2020). https://doi.org/10.1038/s41467-020-19802-w
Another little box landed on my doorstep today, this time with 16 oz of currants plus a pop up laundry basket I was sure I needed to bring some order to my laundry room. Lord knows how many things have come to me via Amazon, well I guess you could go to my “orders” on my Amazon page and see that precisely. I don’t go out and shop anymore, probably much to the chagrin of my local merchants. I was never much for shopping as a recreational activity, but now and then you needed something and had to go out for it. No fighting for parking places with Jeff. I do recall almost Christmas ventures hoping something would strike me as right for a loved one, but no more. Jeff Bezos in his genius has freed us of all that. Whatever you want, there it is. Wow. How can you not bequeath the man his multibillions? Too bad he’s such an ultra liberal but others of his caste have been worse. At least he’s ginned up a good sex scandal, complete with transmission of genitalia. He’ll not have a job in the Biden cabinet. Which is good, so he can keep on his mission of transforming the world’s retail market. Amazon warehouses will be quietly plunked down in obscure parts of the world all over. Press on, Jeff. I’ll keep clicking.
Our cleanliness is killing us. Prof.Carlin alluded to this a couple of posts ago https://wordpress.com/post/theviewfromharbal.com/881. I came across this twitter on the subject and had to share it, even if this is my 3rd post of the day
Once it stops flashing, you can see what I’m talking about. Would be a heck of a way to go, overwhelmed by some superbug resistant to any antibiotic that you might have encountered and developed immunity to while it was on your kitchen counter. More booze, less bleach. We are all God’s creatures..
The AMA ain’t what it used to be. Most docs, yours truly included, have had full and fulfilling careers without paying for an AMA card. Yet, what the organization says still carries some weight, so when they added their heft to the anti-Plaquenil for COVID movement when it first looked like there might be something there, it didn’t help those who remained proponents. So when they slipped the following language into the 10/30/20 addendum to the Delegates Handbook for the upcoming November annual meeting, you’d think we would have heard more about it.
“Resolved, that our American Medical Association rescind its statement calling for physicians to stop prescribing hydroxychloroquine and chloroquine until sufficient evidence becomes available to conclusively illustrate that the harm associated with use outweighs benefit early in the disease course”.
But if you do a Google search on “AMA” and “Plaquenil” all you get are all their earlier warnings, which in this resolution they state were based on potential side effects that did not pan out.
As if the raw data from the pandemic weren’t bad enough, the numbers can be crunched to produce even more depressing stats. One such measure comes from the concept of “excess deaths”. Presumably in any country the number of people who die off each year should be about the same year-to-year. Not so for our almost gone 2020. From March through August of this year, 1,671,400 slipped the mortal coil, leaving 328,052,960 or so behind. That’s all causes. For 173,300 (10.4%) COVID had something or other to do with it. Over those same months in 2015-2019 an average of 1,370,000 deaths were reported. I promised no politics, not no math. So that’s 300,600 – 3 full Michigan Stadiums (not that we’ve seen that for a while) – more bodies racked up this year than we managed to do in the 5 years previous. And only 58% of those could be tied to COVID. There’s another gruesome story there, but that comes later.
Not so fast, said Dr. Meredith Shields and her 5 friends at the National Cancer Institute, using the NCI’s internal research funds to support their deeper look at these numbers. Their paper came out yesterday in the prestigious Annals of Internal Medicine’s online edition*. They pointed out that our country in 2020 is a different place than it was in 2015-9, not just because of COVID. First, there’s more of us; per the Census Bureau, the total population of the US starting this year was 5.22 million persons larger than the average 2015-9. And we’re older. The increase is almost all boomers like me, with 5.04 million 65 or older, 10% more than last year. There were even some decreases in younger age groups, you know, those whippersnappers who do pretty well with COVID. Taking these factors into account, Dr. Shields and friends recrunched the numbers, ending up with 218,000 – only 2 Michigan Stadiums, packed – excess deaths, with now 80% having something to do with COVID. Most of those were in folks my age or older. But the non-COVID excess deaths were primarily in those 25-64. What gets these younger people? Cancer and heart attacks, of course, possibly made more deadly when the hospital or E.R. is avoided. Then accidents, overdoses and suicides, possibly borne of carelessness and despair from having to live under the fear and restrictions imposed by our betters trying to help us. Per Dr. Shields and company, the main causes of death in this younger group were diabetes, Alzheimer’s and heart disease. They did point out that for 28% cause of death was not stated and that the CDC had not yet released data on accidental deaths, drug overdoses, and suicides.
So, it’s been bad, but maybe not as bad as portrayed. Yes COVID can be a killer, but less than 1.9% of the 16,725,039 cases identified in our country this year have died with it, and many of those died “with COVID” rather than “of COVID”. Plus a lot of people have been infected but not bothered to be tested. Living in this pandemic is still hard, with conditions imposed to protect us having a not insignificant impact.
But, hey, they’ve got the vaccine. Two of them. And it’s Christmas! Remember how ol’ Ray sang it: “You only live but once, and when you’re dead you’re done.”
*Shiels MS, Almeida JS, García-Closas M, Albert PS, Freedman ND, Berrington de González A. Impact of Population Growth and Aging on Estimates of Excess U.S. Deaths During the COVID-19 Pandemic, March to August 2020. Ann Intern Med 2020; https://doi:10.7326/M20-7385
From the day I stepped into kindergarten to the day I was handed my M.D. degree was 22 years. I started to get a small paycheck for six years I spent in training, so nearly 3 decades passed before I was ripe enough to be trusted with real patients and to begin to teach others what I knew. That effectively ended 2 Decembers ago, although the U paid me to tie up loose ends and clean up my office for the six months they finished putting me through the meat grinder. Figure 34 years there, three more decades. As my birth mother is 88 and only starting to slow down while her mother made it past 100, I’m hoping I’ve got the genes for 3 more decades. My financial advisor says my money’s not likely to run out.
Except for socking money away, I never really “planned for retirement”. Medicine is a harsh mistress, although she offers ample rewards, not just monetary. My joy was always in joyfully doing what I had to do. After that there often wasn’t much time or energy for anything else. In med school, I learned to take pleasure in the mundane chores of everyday life: cooking, eating, drinking, laundry, cleaning, exercise, maintaining an old car, and chasing women (rarely mundane, but surely one of life’s necessities). 25 years ago, I began brewing my own beer, probably the closest I ever got to a “hobby”. Great use of all that chemistry and biology I had to study. I stopped once the craft beer revolution got far enough along you could go out and easily buy some pretty tasty stuff someone else had made for you. Sure, I enjoyed sports, particularly my Wolverines, followed politics, listened to all kinds of music, and liked to go places with my dear wife, who shared so many of my interests. We were avid bicyclists, owning 6 bicycles of various types between us, but that all stopped abruptly when I had a bad accident in Chile 6 years ago.
So what does a retired doctor do? I thought I would miss clinical medicine much more: the daily challenge of figuring things out, the gift of having to give of yourself to others, the variety of people with whom you come in contact, the gratitude from the occasional patient you’ve actually helped, the satisfaction of seeing a trainee finally “get” something you’ve been trying to teach them, your colleagues and co-workers (well, some of them), and the opportunity to publish on something new you yourself have figured out. All of that is gone, well except maybe for the very last item. But what’s also gone is having to listen to people tell you about their aches and pains all day while expecting you to do something about it. Can’t say I miss that at all. I still have an active license, and now and then someone will ask for some free advice and I give them their money’s worth. Every so often, I put on my white coat, yellow tag I.D., and scrubs and go into the Medical Procedures Unit to watch a young protégé begin to master a biopsy technique I’d been doing for all those 34 years which some of my ex-colleagues decided maybe they missed after all. I was worried during the first wave of COVID I’d be pressed into action, but other than a batch e-mail from my Chair seeking volunteers to staff the new medical services, nobody asked me, at least not nice enough for me to consider the offer seriously. Whew. That’s a lot of war stories I’ll never get to tell, but I appreciate being spared. With conferences and faculty meetings virtual, it’s easy to participate in them when they look interesting. I’ve been asked to deliver one myself next week. One of my former fellows asked me to participate in the combined Beaumont/Wayne State/Henry Ford journal club. I envisioned myself being the crusty old fart in the back of the room, grumbling that this stuff isn’t new; we’d figured that out a long time ago. A role I’d been preparing for all my life. Unfortunately, I came away from my first experience 2 nights ago with a sense of relief that I don’t have to know that stuff anymore. I’ll still give them another try. I haven’t yet uttered my first grumble.
But there’s another part of Medicine that remains active: publishing. Early in the lockdown one of those “predatory” journals asked if I’d write something for their special issue on arthroscopy. Flattered, I did. “Predatory” journals take advantage of the “open access” concept. Regular journals won’t allow access to their articles without a subscription. In academia, the medical library pays those fees, so the doc seeking an article never has a problem. Others outside the institution can pay for a single article rather than a full subscription, but the charges can be steep. In “open access”, the author pays the fee in return for having his work always available for free. Most legit journals now offer this as an option and some have gone to complete open access. Occasionally, the author’s institution or professional society will cover this fee, but authors with research grants just include these fees as part of their research costs. A cottage industry has sprung up of journals reaping open access fees from authors they’ve solicited with flattering e-mails. I get them every day. In my case, one of my co-authors, Ken, had a little slush fund he agreed to dip into and off we went (1). What we ended up with looked so good, I decided to buff it up and flesh it out and try to get it into the premier journal of my specialty: Rheumatology (Oxford). Yes, that Oxford. Lo and behold, that got in (2)! I next wrote a commentary on joint washout for knee osteoarthritis, which I had done and had written about for many years but had fallen out of favor. Incorrectly, I argued. And that got in (3)! I have 2 other completed manuscripts ready to go. The longer one has been kicked back by 2 European journals, but I’ve got some guy in Sydney interested. The shorter one was sparked by another request from a “predatory” journal, but came out so good we’re going to try the waters of the legit literature. A couple months back, I was contacted by one of my heroes, Roy, about joining him and 4 other guys trying to buff up their paper on hyaluronic acid in knee osteoarthritis, something I’m done research on, written about, and done enthusiastically for many years. I should be working on that right now instead of typing this. Once these 3 get in, there’s more! I keep putting more and more things into my paper that will be a guide on how to publish in the rheumatology literature. In various stages of development are papers on salivary gland biopsy, assessing competence in arthrocentesis, muscle biopsy, and making something out a book of cartoons my New Jersey friend Angel drew about arthroscopy while still in Cuba. Oh, and the editor of the journal Arthroscopy wants me to write him a letter describing my Rheumatology (Oxford) paper and how to access it. Kicker is I have to get Oxford Press to waive or substantially reduce the $4225 open access fee so Arthroscopy’s readers, almost all orthopedists, can get at it. I wrote that e-mail last week and have yet to hear back.
Writing for WordPress is much simpler. No editors, no reviewers, and no fees beyond the modest, and well worth it, annual. I’ve probably had more than 100 posts since I first started in mid January. COVID has inspired many posts, but I have other stuff to write about, like this one.
Back when I was practicing, some of my old guys would say something, commenting on retirement, like “I don’t know how I got anything done when I was working”. I used to wonder what that was all about. But I got it pretty quick once I retired myself. Work and its pressures keep a lid on so many things you’d like to do but can’t, or can’t do much, and on things maybe you never thought about doing in the first place. My late dad, who put in 31 years at Fisher Body (G.M.) before happily retiring at 51, one of the first salaried “30-and-outs”, and spending 2 more years retired than he’d spent working, used to say that “GM” stood for “Great Monopoly”, as in a “Great Monopoly” on a person’s time. I understand that now, too. Maybe UM is the “Ultimate Monopoly”. Anyway, I’m happy to be out from under. Now there’s time for shopping, cooking, hiking, decluttering and organization, music, reading, travel, connecting with my high school classmates (VHS ’70, 50 years out!), spending time with my dear wife, whose virtual teaching keeps her right by me in the living room, and of course writing. And I can be what William Shatner told me to be 4 Januarys ago: open to new possibilities. Now I’ve got the time.
Ike RW, Arnold WJ, Kalunian KC. Arthroscopy in rheumatology: a reminiscence. J Surg Surg Technol 2020;2(1):27-35.
2. Ike RW, Arnold WJ, Kalunian KC. Arthroscopy in rheumatology. Where have we been? Where might we go? Rheumatol (Oxford). Epub 2020 Dec 1. https://doi: 10.1093/rheumatology/keaa560.
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