Medical Discussion of Coronavirus

[Lithium]

Is this honestly a realistic scenario you see on a routine basis? I'm somewhat shocked at your reasoning for prescribing them unindicated medications. If they were on inappropriate psych medications (not prescribed by you) would you continue them as inpatient? As I tell many of my patients, I can't control what other physicians do but I can control what I do.

It really depends on what the goal of the hospital stay is and if there’s a possibility of getting a buy in from the patient’s outside physician. I don’t as a matter of course try to taper someone off of benzodiazepines which they’ve taken for years unless I know their primary psychiatrist or PCP is on board. Obviously if someone is shooting heroin they’re not getting restarted on their Percocet. I know that technically my name is on the medicine and I’m “prescribing” the medicine, but I rationalize to myself that I’m just continuing something I don’t agree with for a few days rather than really making the decision to prescribe it myself.

[Lordosis]

I get what whoever put this graph out is trying to prove but this is likely a very deceiving graph for multiple reasons.

Are there really counties that have 0-10% and 90-100% voting for one or the other? That alone makes the data suspect to me.

[CordMcNally]

Are there really counties that have 0-10% and 90-100% voting for one or the other? That alone makes the data suspect to me.

There are many small rural counties that voted at least 90% for Trump but these counties typically only have a few thousand votes at most. It looks like there were a handful of counties that went the other way, too.

An Extremely Detailed Map of the 2020 Election Results: Trump vs. Biden - The New York Times (nytimes.com)

[AR]

AR, I get what you are saying, but I'm weary of the "customer is always right" medicine. A) If they had gotten vaccinated, they probably wouldnt even be in hospital. B) If the doctor is such a superstar, he should at least be on the medical staff of a real hospital with other real doctors. C) Words (or in this instance, malpractice) matter.

This isn't really customer is always right. I'm also not convinced that giving ivermectin in addition to standard therapy is "malpractice". I'm pretty sure zero docs have lost their licenses for prescribing Ivermectin for COVID and zero will.

The prescribing doc in this case could point you some articles that show some questionable benefit. He could say that he has experience giving to X patients with good results. Sure, he could publish it but it will be too late for this patient by then. Also the drug is is really quite safe.

So in this case we have a patient requesting a therapy that another fully licensed doc recommends and the patient is in a predicament where they can't just go see that doc somewhere else. Also the risk of harm is very, very low.

Like I said, I'd still fight it myself. So we're definitely in agreement on that. I guess the only difference is that I wouldn't feel quite as bad about losing as you would.

[AR]

I guess I don't know why you'd assume the doc is otherwise unobjectionable if he's willing to prescribe a medication with no benefit at this stage of the game. Also, it takes 60-90 days to credential someone. Why does the quack get to jump the line? I don't think this is a precedent we want to set.

To reiterate, I'm not in support of this at all, but I'll play devil's advocate.

In reporting where the doc is mentioned, it's easy to look up to see if they have any complaints with their state medical board. I did that a couple of times and came up empty. Also there is pretty much no one is going to lose their license over prescribing ivermectin for COVID. It is not even close to meeting the threshold for license-losing malpractice. Docs do non-standard, unconventional stuff all the time. If docs lost their license for doing something with little to no literature support, we would have a lot fewer licensed docs.

Also, there is some scant evidence of ivermectin doing a bit of good. It's not great evidence, imo. But it's published and it exists.

The reason why the "quack jumps the line" is because you have a unique situation where the patient cannot wait and presumably the patient can't be moved elsewhere.

I agree that it is a precedent we don't want to set. And that is one of the reasons I'd fight it. All I'm saying is that if I lost, I wouldn't feel terrible. I am very strongly in support of patients doing whatever they want (even stupid things) with their bodies as long as they are fully informed. In this case, the injury to the hospital (credentialing a doc who is willing to provide that care) is pretty minimal in a vacuum. So I can understand why a judge would rule the way they did. And I wouldn't like it, but I wouldn't feel that terrible about it.


Once again, I'm not an ivermectin advocate. I just want to be clear on that.

[AR]

Of course they are cherry picking the data out of political motivations. You could also invert the graph during previous waves when the Northeastern US had higher mortality than the south, but I doubt that came up from whoever created that graph. This country is honestly sick with politics from both sides. Extreme fringe elements on both ends drive the narratives.

Do you have some links handy to these inverted graphs? I would be very interested in them.

[Lithium]

I guess ivermectin is less harmful than hydroxychloroquine? So maybe the trick is to spread misinformation about things that are possibly good for patients anyway. Hopefully after the ivermectin craze is over, someone will start hyping fish oil.

[CordMcNally]

This isn't really customer is always right. I'm also not convinced that giving ivermectin in addition to standard therapy is "malpractice". I'm pretty sure zero docs have lost their licenses for prescribing Ivermectin for COVID and zero will.

The prescribing doc in this case could point you some articles that show some questionable benefit. He could say that he has experience giving to X patients with good results. Sure, he could publish it but it will be too late for this patient by then. Also the drug is is really quite safe.

So in this case we have a patient requesting a therapy that another fully licensed doc recommends and the patient is in a predicament where they can't just go see that doc somewhere else. Also the risk of harm is very, very low.

Like I said, I'd still fight it myself. So we're definitely in agreement on that.

Some may see this as a rather dramatic argument from myself and maybe it is but if you're not practicing good medicine then why are you a doctor? Seriously. This isn't directed at you, in particular, but the entire physician community. If you can't stand up for practicing good medicine against a minority of physicians and any administrators that want to question your practice (and for the patient's benefit) then I question what you're doing. Try going into the C-suite and telling them how they should be running the hospital as a business. See if they incorporate your ideas. I doubt they do. This is one of many reasons why we are proving ourselves to be replaceable by those lesser trained. You're (the collective you) a physician so stand up for yourself and start acting like it.

[Zaphod]

Well, I no longer sit on C&P, but I guarantee you that I would not be strong-armed to credential a quack and I guarantee you that a judge will not strong-arm me to practice poor medicine. If this is non-fiction, it is yet another demonstration of the complete castration of the medical staff.

Or, more than a few quacks on staff which is much more likely.

[AR]

Some may see this as a rather dramatic argument from myself and maybe it is but if you're not practicing good medicine then why are you a doctor? Seriously. This isn't directed at you, in particular, but the entire physician community. If you can't stand up for practicing good medicine against a minority of physicians and any administrators that want to question your practice (and for the patient's benefit) then I question what you're doing. Try going into the C-suite and telling them how they should be running the hospital as a business. See if they incorporate your ideas. I doubt they do. This is one of many reasons why we are proving ourselves to be replaceable by those lesser trained. You're (the collective you) a physician so stand up for yourself and start acting like it.

I'll start with the standard disclaimer that I'm not a supporter of ivermectin use in COVID.

I'm not sure any of above (which I agree with) has anything to do with the matter at hand.

Obviously these ivermectin prescribers think they're practicing good medicine. The thought process could very easily be something like "Well the risk of harm of Ivermectin is very close to zero, and based on this study I read the risk of benefit is also close to zero, but still an order of magnitude higher than the risk of harm, so giving it is probably a reasonable thing to try. Especially if the patient receives otherwise standard care."

To be honest, on occasion, I've had similar thought processes when recommending other treatments to patients. I'd be surprised if most docs haven't.

Once again, I'm not a supporter of ivermectin use in COVID.

[Zaphod]

Cant see the graph for what people are talking about but given context I think its actually very important and indicative. There is no way an area that had prior warning, testing, was locked down before spread should allow themselves to catch up to a place that was caught flat footed with zero tests, treatments, and one of the most densely populated heavy public transport etc...especially when they had a vaccine available for almost a years time.

Its just plain failure.

[CordMcNally]

I'll start with the standard disclaimer that I'm not a supporter of ivermectin use in COVID.

I'm not sure any of above (which I agree with) has anything to do with the matter at hand.

Obviously these ivermectin prescribers think they're practicing good medicine. The thought process could very easily be something like "Well the risk of harm of Ivermectin is very close to zero, and based on this study I read the risk of benefit is also close to zero, but still an order of magnitude higher than the risk of harm, so giving it is probably a reasonable thing to try. Especially if the patient receives otherwise standard care."

To be honest, on occasion, I've had similar thought processes when recommending other treatments to patients. I'd be surprised if most docs haven't.

Once again, I'm not a supporter of ivermectin use in COVID.

The difference with other medicines we may use without significant risks and benefits is that we don't have multiple professional groups, government groups, and the manufacturers of those medications coming out and explicitly saying don't use that particular medicine like we have with ivermectin. With that said, if we get good data that shows clinically useful benefits then I'll be happy to change my stance.

[AR]

The difference with other medicines we may use without significant risks and benefits is that we don't have multiple professional groups, government groups, and the manufacturers of those medications coming out and explicitly saying don't use that particular medicine like we have with ivermectin. With that said, if we get good data that shows clinically useful benefits then I'll be happy to change my stance.

I don't think that's really different at all. For many non-standard therapies, you will generally find mountains of evidence and practice guidelines recommending against them. Yet some docs will still prescribe them. The only difference is that there is more media coverage with ivermectin (for obvious reasons). I don't think the amount of media coverage something gets should inform us on how to practice at all.

To reiterate, I don't support the use of ivermectin in COVID.

[CordMcNally]

I don't want to sound like a ivermectin fan, because I'm not.

Once again, I'm not a supporter of ivermectin use in COVID.

To reiterate, I don't support the use of ivermectin in COVID.

I honestly don't know why you're such a huge fan of ivermectin...

[Jaqen Haghar MD]

So data is correct... I made this point months ago, it's not political. In a large national survey at the time, no single demographic factor was more closely associated with vaccine acceptance/refusal than political affiliation. Put another way, being a self identified Republican was the single greatest risk factor for the ideology of vaccine refusal. I think we also know that Republicans are more likely to support the ideology of mask refusal. Seems highly relevant to me, like knowing that smoking and radon and asbestos exposure are the greatest risk factors for lung cancer, now we know who to screen and potentially what interventions need to be tailored to reach this population, which is suffering disproportionately from the pandemic. In the early days of the HIV pandemic, it was useful to know it was mostly a disease of gay men, right? That's not political, that's basic epidemiology, now you target and tailor your public health message.

It’s interesting really. During the time period specified, Texas and Florida accounted for the majority of Covid cases. This graph does not include any data from Florida. The two most populous counties in Florida are Miami-Dade and Broward, both are generally blue counties. Both of these counties had very high covid numbers.

In the area I’m in, the minority communities are extremely distrustful of and reluctant to get the vaccine. They definitely don’t lean republican. As far as hospital employees that are unvaccinated, in the majority, you would likely find political leanings to the left here.

The point of the graph is not epidemiology. It is to link “Trump” in the title with bad Covid statistics. It’s a marketing technique. I guarantee that the person who made the graph started with a premise and then sorted the data and titled it, to make their message.

I bet that early in the pandemic, when NY, NJ, MA etc had horrible Covid outcomes and high mortality rates, the same authors didn’t produce a graph titled…. “COVID Deaths by state vs Hillary % Vote”, but they could have, and some idiot probably did, as Trump himself mentioned it at the time.

It’s all very complicated in a way, but don’t get me wrong…. I hate all politicians in both parties equally, especially as they get out there on the edge of their respective sides of the viewpoint bell curve.