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Anonymous Mailbag

It’s Tuesday, time for the anonymous mailbag and I hope all your lazy asses are back to work by now.

As always you can email your anonymous mailbag questions to claytravis@gmail.com.

But this week is going to be a unique anonymous mailbag. (Don’t worry, we’ll be back with your usual mishaps and shenanigans next week).

Two weeks ago I asked doctors to email me if they had opinions they would like to share about the coronavirus and we were deluged by Outkick doctor emails. (It would trouble my critics to no end to know how many people in the medical community read this site regularly.) It’s worth noting that most of these emails were sent around ten days ago so if they are a bit dated, that’s why. It’s also worth noting that I asked each doctor to email from their practice or provide credentialing to confirm they were who they claimed they were.

Almost all of these doctors requested anonymity to share their opinions.

But not the first emailer who was fine with his name being used. We begin with him.

Dr. Adrian Gaty, who wrote as follows:

“Hey, regular reader, never written before, but you asked for it. The Virginia pediatrician from the mailbag is right on, as you have been for months. This is insanity.

Pediatricians pride themselves on being good advocates for their patients, since kids often can’t speak up for themselves, but our institutional response has been pathetic. We have amazing, almost miraculous data showing that our patients, unlike the patients of almost every other specialty, are at statistically zero risk from this disease. Our big associations should be shouting it from the rooftops! Instead, silence, or even outright fearmongering, buying into the ‘stay home stay safe’ government guidelines. Sickening. 

And our parents are thirsting for our leadership. I published the below article on my practice’s website earlier this week, and received a really positive response from lots of patients. I think they thought this stuff was all hooey, but were afraid to act on their guts or on clay travis’ opinion, but hearing their pediatrician say it gave them the peace of mind they needed to let theirs kids go play outside with their friends.”

Here’s that article:

Let Our Children Go

It’s never been a better time to be a newborn. Knowing the dangers posed by even mild colds, many of our parents will stay secluded for weeks after their child’s birth – they’ve been social distancing since before it was cool. Families who once lived in fear of the friendly lady at church can now rest at ease as a masked populace gladly keeps its distance. For those of our patients over 2 months of age, however, things aren’t going quite as smoothly: we are on the precipice of a mental health disaster.

Before the pandemic, American children were already suffering from anxiety and depression at unprecedented levels. Two leading contributors: isolation and isolation’s handmaiden, screen time. It is not just that screen time itself has negative mood effects, but that the time spent on screens takes away from the best mood booster there is: spending time with your friends, in real life, face to face. With our “new normal,” kids are stuck home, stuck alone, and doing all their work on … screens. Our mental health risk factors will not take a holiday just because the public health experts want them to. Given the trends before social distancing, what do you suppose will happen now that society is coming together to force our kids to stay apart?

Our new epidemiologist overseers will reply, if it saves one life, it’s worth it. Well, it may literally save just one life. None of us will forget the harrowing scenes out of Italy. Of all those tens of thousands of dead, however, there have been only two children. New York has been our worst hit city, yet among the thousands of deaths, there have been only three children, all with underlying conditions. We were right to be cautious in the early days. Now that the data is coming in, it is time to reconsider. Any parent would rather have a miserable child than a dead child – but if your child’s chance of death even at the epicenter of the worst outbreak is statistically zero, the moral calculus changes. Given the remarkably few worldwide child coronavirus deaths, it is reasonable to predict that significantly more American children will die from social-distancing-prompted suicide than from the virus itself. The time has come to let our children go. Go outdoors, go play, go free.

A common argument against the liberation of children is that, while they themselves are not in danger, they can spread the illness to those who are. The science behind that assumption is sketchy, at best. In both Australia and Switzerland, for example, public health authorities have declared that children are not significant vectors for coronavirus. Even if they are, though, is that reason enough to imprison them indefinitely? Not if there’s another option. Luckily for us, there is. Most kids have friends who happen to be… other kids. Of course children should not be allowed anywhere near nursing homes right now – nobody should! Protecting the vulnerable must be a priority. Letting kids play with other kids, and preventing them from descending into madness, is another priority. We can do both. The alternative – indefinite, soul-crushing detention – is simply inhumane.

Parents, do the right thing: kick the kids out of the house. Public health officials: support parents in their efforts to keep their kids healthy by keeping them social. Communities: reopen your youth groups, sports leagues, daycares, and schools. As for the elderly, I trust you will want to give your grandchildren the gift of happiness, knowing it won’t pose them harm. If worried for yourself, continue to keep your distance. We have never closed society to protect our youngest, vulnerable though they are. For now, it seems you and all our newborns may be in the same boat.”

Next doctor email.
“Hi Clay.  Thank you for all that you have done to speak factual evidence during this time.  You can see a link to me here. I am board certified in family medicine and addiction medicine.  I also have a Master’s in Public Health.  I will also attach my cv for you.
I am embarrassed by our country’s response to COVID-19.  Coronavirus is the Notre Dame of infectious diseases. It is living off the hype of past pandemics and has the media telling us how great it is all the time. It keeps winning against weak competition every week but has not faced Alabama yet. I must say that the brightest minds in medicine do not go into public health or work with the government for a career. Most doctors can’t afford to live off very low salaries. The longer sub-specialists are out of work I hope they will be listened to more. Anyway I feel like I am taking crazy pills. My wife does not even listen to me about the real risks of this virus (I guess that is part of being married).
There is no scientific evidence that social distancing and maintaining 6 feet apart from people at all times will save lives. There is also evidence that healthy people wearing masks put themselves at higher risks for other viruses (as they are making it more difficult to expel virus particles from their respiratory track.) There is no reason to quarantine healthy people who are asymptomatic. We need them out and about building herd immunity. We need to focus our efforts on the people at highest risk (nursing home patients and the very sick).  One of the issues with the media coverage is their focus on “pre-existing conditions” putting you at higher risk. Many people have one chronic illness (but even so they are not at high risk of death).  They don’t specifically talk about what conditions and increase risk and this spreads more panic.

I practice addiction medicine full time and am dealing with the opioid epidemic during the pandemic. Social isolation is the worst thing that can happen to my patient population. Most of them do not have stable or safe environments to  shelter in. They also often work in restaurants and in construction (and are now out of work and relapsing at higher rates).  Looking at the data there is no reasons for our country’s response, and I fear that we will have many other public health problems due to unemployment in the future.  

Another doctor:

“Been listening to your show for the past 2 years and have enjoyed your perspective on politics.  I am an Alabama pediatrician who has watched in growing horror at our country’s mass suicide. One thing we emphatically know about this illness is it’s complete disinterest in children.  That is extremely unusual for any virus.  
Even though we are not exactly sure why this is the case, we can see the data that proves it. This is a fact that should be celebrated far and wide, but now I get to see my Academy (American Academy of Pediatrics) trumpeting the concern of a few children with inflammatory processes like Kawasaki’s disease.     
It is crazy that myself and my fellow clinicians in a very large pediatric practice have seen our clinic numbers drop off a cliff over the last 2 months.  Many children are not getting their vaccines.  It would be tragic to see the return of illnesses like measles, chicken pox, meningitis, and severe pneumonia.  And these are things we can control. Dr. Fauci completely lost me last week when he decreed that it would be unsafe to start school next year (we shouldn’t have stopped it this year).  That kind of fear keeps kids away from the doctors who help keep them well, and should be of concern to an epidemiologist worth his or her salt.  Also, when he declared we won’t be “safe” without a vaccine, nobody asked him the obvious question, “What if we can’t develop a vaccine?”  
Realistically, we can’t continue on this path.  It is too damaging to our country, economy, and our families.  Time to start moving out.  I am thankful to live in the great state of Alabama, where our 75 year old former teacher governor has been able to judge and make the hard decisions necessary to move forward.  I am very disappointed in my fellow physicians who seem so terrified of getting sick from this.  I hate to say it, but that’s part of the job.  You are paid well and respected, but that also carries inherent risk.   The data shows that the majority who get it will be asymptomatic or will have only mild symptoms.  I am older so at slightly higher risk, but am willing to trade that to continue to take care of my family.  To quote a courageous 74 year old ED doctor in New Orleans, “Ships are safe in a harbor, but that’s not what ships are for.”  He is there working all his shifts to use his vast experience to serve his community.  Which is what we all should be doing.  Thanks for letting us air out a different perspective.  I would request anonymity so that my other partners wouldn’t get any grief, I am one man with an opinion.”
Another doctor’s take:
“I appreciate your efforts to provide rationalized opinions on our response to the Coronavirus. Realistically, there are actually two “viruses” at work here: the biological SARS COV 2and the economic “virus “ which represents a fear virus. The behavior of the biological virus has received much more scrutiny from the general media than the more insidious and highly destructive economic/ fear virus. 
 
No doubt there are areas, communities, and families that have suffered great loss as a result of Covid and I don’t want to minimize their grief. But the coming destruction from the economic virus has a much farther reach than the biological one. The United States spends more on healthcare than any other nation. I know that many hospital systems across the country are now in serious financial crisis never having seen a surge in Covid cases. In the medical system where I practice, many employees including nurses and those providing direct patient care, have been fired, furloughed, or  had their positions eliminated. All employees have had salary cuts and major sources of revenue such as surgery and other procedures have been postponed or canceled. Research efforts have been curtailed by stay at home directives. There is likely much more damage to come.
 
We never had a surge of Covid patients at my hospital that had been feared. Our emergency rooms and ICUs were not overrun. We didn’t run out of ventilators or PPE. Yet in the midst of this global pandemic we as a country shut down the economic engine that fuels our ability to effectively and aggressively respond to the consequences of the health crisis. If there is a resurgence of disease at some point, how can we effectively respond when our facilities have slashed the number of caregivers and are so financially strapped they can’t provide basic services? Predictions were made that we would overwhelm our health system when it was strong and robust. What do we do in the fall and winter if Covid cases surge and we have no resources or caregivers to respond? 
 
We as individuals need to be brave . We live in a world where many things can kill us and we take many steps to mitigate the dangers. Despite our efforts to curb smoking, make our cars and roads safer, reduce cancer, heart disease, obesity, diabetes, gun violence, HIV, infant mortality, and drug abuse, they remain major causes of death in this country.  It is unrealistic to think that we can eliminate Covid as a cause of death at this time. However we can mitigate the effects of this virus without hiding in holes.  
 
The world needs PPE for healthcare, public, and private use. We need medications manufactured in this country that are not so vulnerable to supply chain disruption. We need technology and infrastructure built for quick pivots to address rapidly changing needs. We need new and better ways to care for the most at risk populations, including revolutionizing nursing home care. We need extensive contact tracing. We need research and manufacturing for treatments and vaccines. 
 
During WW II, production in factories was shifted to produce tanks, Jeeps and planes to fight a war. We should use a similar concept to produce massive amounts of PPE, ventilators, testing reagents, and medications made in our country that will serve to put people back to work and keep us from ever having to shut down again. And if we mobilize our economy with clear goals and proper incentives to create employment opportunities for this new reality, we can fight the economic “virus “ with the job needs that will be created by these endeavors. 
I know your opinions differ from many in the general media about the seriousness and deadliness of the Coronavirus. I agree with many of your points but I also know the virus has not been around long enough to know everything we need to know about its behavior. If wearing PPE everywhere we go makes us all feel safer while simultaneously creating jobs from the increased need, then let’s put a nation to work doing it. If we allow the economic virus to destroy our ability to respond to the healthcare demands of our communities, both biology and fear will win. We need to both cautious AND brave. 
Be brave America or as Clay might say: Get back to work and DBAP. 

Thank you for allowing physicians to use your platform to share our opinion.  I have around 1,500 Facebook friends (I know this is not a lot, I’m only giving you the number for perspective), and I am afraid to state all of my opinions on social media (I have posted and debated some opinions, such as the need to reopen schools, and I only do this because I have “dogs in the fight” and the evidence to open them seems overwhelming to me).  I’m afraid of the backlash of the laypeople naysayers who are ignorant regarding infectious diseases.  I’m afraid of the backlash from medical doctors who have someone become suddenly ignorant to the fact that there is more to our life than healthcare.

1) People in the medical community are no better than people not in the medical community.

If you took a random sample of the general population and compared it to a random sample of medical workers, they would be essentially identical.  Yes, for the most part the medical community doesn’t have homeless people or a ton of drug users, but you know what we do have?  Self-righteous assholes who love attention.  I can guaran-damn-tee you that the VAST majority of your medical friends posting on social media are seeking attention.  They are absolutely eating up the “medical hero” bullshit.  I served 11 years in the Air Force as a physician; I worked in Germany, Afghanistan, Puerto Rico after hurricane Maria…. I’ve seen heroes.  And yes, heroes did go and are going to work in places like NYC, but NYC ain’t everywhere.  If you are at a regular community hospital, where the vast majority of healthcare workers work, your job has gotten EASIER with COVID-19!  My guess is, if you think about it, the people you see posting these things have a hint of narcissism in a lot of their posts.

2) The media is insane with this, but this is nothing new.

The other day while walking through our Physician’s Lounge, Good Morning America was on.  They were running a segment on a “mysterious illness” affecting children in New York State, and physicians in Europe had noticed a similar syndrome.  GMA devoted 10 minutes to this…. For 3 kids in the entire state of New York!!!  And the thing is, although there is a good chance this syndrome has something to do with the SARS-CoV-2 virus, there is also a good chance it has nothing to do with it.  I watched with my mouth agape.  And, predictably, throughout that day I was getting messages from fellow parents asking if I had heard of this, asking if it changed my mind about opening schools, asking if they should stop letting their kids outside (these are parents whom I’ve talked into letting their kids play with other kids).  

Do you realize if you go to Statista.com right now (5/15/2020 at 3 pm), NYC is reporting ZERO deaths in people ages 0-17.  There is an unpublished study on its way to publication that is citing a mortality rate of 1 in 300,000 people ages 0-20.  1 in 300,000!  That’s not 300,000 people in the general population, that’s 1 in 300,000 kids who actually acquire the SARS-CoV-2 virus!  And yet, GMA has parents terrified.

3) We should open up schools (and everything else).

In America we do things the American way.  What I mean by this is we are a country founded on principles like liberty and freedom.  China was not founded on these principles.  China can lockdown and take away freedom because freedom isn’t their culture.  China can wait on a vaccine.  In America, we can’t wait on a vaccine.  We need this virus to circulate through everyone ages 0-40, period, and the only way for that to happen is to open schools (and of course send people back to work).  Of course it should be done with certain mitigating features (older teachers stay home, high risk children stay home…. I think parents should have the right to not take their kid to school if they’re in the position to make that work.  But lockdown until a vaccine comes is not an option in America, and the quickest way to make an open America safe for the most number of people involves open schools.

Several dentists wrote in as well, here is one of them:

“I’m a dentist in Texas. Like you, I’ve been amazed by the lack of data used to analyze the situation. After 7 weeks of government mandated unemployment, I was eager to get back to treating my patients when we were allowed on May 1. And nearly every dentists I know is right there with me. 

Now consider this: we voluntarily chose a profession that puts us at high risk of infectious disease. Everyday we use hand pieces that spray water in the patient’s mouth creating aerosol. We use all sorts of sharp instruments that can draw blood. We know what to do in order to prevent the spread of disease. This was true pre coronavirus and is still true now. Knowing the risks, I’m ready to treat patients. As a wise man once said, DBAP unless you need to SBAP. I have a responsibility to my patients to treat their oral health. And I have a responsibility to my coworkers/employees to provide them with a means to make a living. Reasonable precautions are being taken like health questionnaires, temperature screening, hydrogen peroxide rinses, etc.  But SBAP when a patient has been coughing, has a fever, or been around a COVID patient. They’re still rare, but these patients get rescheduled. However we always reschedule sick patients. I don’t treat patients with active infectious diseases like bronchitis, influenza, strep throat, or herpetic lesions. 

Anyway, we’ve now seen patients for over 2 weeks in Texas. If the virus was really as deadly as the coronabros claim, you would think aerosolized saliva would be creating clusters of coronavirus infections in every dental office across the state. I’ve yet to heat of a dentist, dental employee, or patient becoming infected with coronavirus.” 

Finally, this one is long, but it’s incredibly detailed on the larger health care issues arising predicated on a particular specialty:
“I am a practicing Ophthalmologist in Providence RI — literally between two major epicenters of the virus.  I think I can provide a unique “how has this affected medical professionals”-type discussion.  I’ve never written anything to a response like this, but felt compelled to.  
For the record, I want to say that I supported and followed CDC guidelines throughout this ordeal —shutting clinics to just emergent and urgent cases in mid-March like many of my colleagues at the direction of our Ophthalmic Society’s guidance.  I thought at the time (and still do) this was reasonable — to a certain extent.  However, as the data was becoming far more clear where our risks were, it was clear we were not learning from that data.  We’re in a political trap:  one in which Governors don’t want to risk being responsible for more deaths from “opening too fast” rather than the goal of “keeping the curve flattened.”  The goalposts have been moved.  I’ll pass on the worst though that this is being kept down to prevent a Trump re-election for now.
It is clear, and was fairly clear early on (ie early April or even late March) that we in the US had a problem infecting the elderly, particularly in nursing homes and assisted living facilities as well as people with certain co-morbid conditions that put them at risk.  In many states, mine being one, the Governor had policies written that forced nursing homes to take people from hospitals ready to be discharged infected with the virus into facilities that ultimately lead to spread like pouring gasoline on grass that was already smoldering.  The idea was that we were so concerned that hospitals and ICUs were going to be overrun, that we had to “clear space” for those coming (ie like we saw in NYC).  This proved to be devastating. I’m not sure anyone has written a paper on SARS-CoV2 and the impact of each Governor policies specifically in this regard to infecting people going from Nursing Home to Hospital and back infected, but my guess is that if someone is allowed to research this, it would be a devastating political problem and a key cause of death in most states (in RI the number is hard to track as they stopped reporting who died from these facilities, but people estimate it to be 65-75%!  When they stopped reporting it was >60 of our deaths).  Your point today in the Mailbag about this being higher is, without a doubt, true. 
That said, the Federal Government also deserves a huge fat F grade as well.  The failure of the Federal Government to coordinate this response to a competent level — I’m talking about the CDC test set up/ramp up/availability from the start (ie required a US test only and it was contaminated in production), procuring and purchasing PPE, ect and distributing that to states and localities rather than having each compete with each other was downright awful as well. The resistance in coordinating ventilators to places of need instead of “making” them was a huge mistake.  We’re now going to have 60K ventilators by the end of June for what?  To store?  Objectively, there has been inconsistent messaging (not this President’s strong suit) and frankly, he’s not been reassuring and calm often times proclaiming treatments that are not based in fact.  The President, as the head of Government will have to answer to that.  In his defense, the press and many working in government are looking to embarrass him in any way possible to deliberately damage him.  Both his failures and the failures of professionals to due an objective job reporting on this are wrong.   The ridiculous political potshots from the opposing party are tragic as well.  
I could go on about the failures here up and down, but I wanted to discuss how this situation has affected my practice and the “business” of Ophthalmology in New England.  I’m a Southerner that came north for work and find myself trapped here. 
As opposed to most other regions that are re-opening in the South, the higher infection rates involving New England and states to the West including NY, PA, NJ (many of who fled here to second homes/family to get out of there and spiked our numbers), from a political viewpoint, prevent us from opening back up like our Southern state colleagues.  You’l recall Governor Raimondo tried to halt NY tagged cars from entering without quarantining when we saw the flight out of NYC and Cuomo bashed her.  She was right to do so.  He got press for this and said it was unconstitutional.  However, we were preventing NYers from here, just tracking where they were going and telling they had to quarantine for 14 days.  While the former is creepy and skirts constitutionality, it’s not a complete deprivation of liberty.  Further, I say political viewpoint, because being in proximity to both Boston and NYC we’re so interconnected, it’s hard to have one state be greatly out of step from another AND the optics of being wrong if that decision was made is a political death sentence for Governor seeking cabinet positions in a new Administration should that happen.  Let’s be clear that’s in play.  So, the fact is that New England will lag other regions just because of decision baed on optics and ideology.  This is a false choice and the consequence of our two-team breakdown.
This largely Blue State idea we can test everyone (no one is honestly taking about false negatives and false positives of the actual tests in this discussion) and control the spread is laughable.  You can’t test 330 million people on a weekly basis.  You can’t even do 10% of that meaning you’re not going to get “in front” of a dynamically changing situation.  So, the logical plan would be to stop.  You can’t track every positive, and their interactions once it’s in a “community spread” situation like we have in the US when many are asymptomatic or already had been infected (assuming you’re not going to “reinfect”) is not mathematically possible with limited resources.  The infrastructure it would take and cost would be more than we spend on Medicare every year.   So, in summary, this idea of spending more and more money trying to find every last positive is not worth the cost and the time to do it renders it impossible.  Why the Administration and the CDC won’t say this is problematic.  This is a leadership vacuum but fostered by the “fake news” phenomenon.  However, people just retreat to their teams when honest, objective information is required.  No one believes anything from the other side and politically, this is being used to separate opposite viewpoints further.  Objectively, this is the result of a President acting out publicly against unfavorable coverage and that same coverage not providing objective, truthful reporting to damage this President.  They both can be true.    
Second, like you’ve pointed out, the cost of closing in economic destruction and lives lost from all the elements of a depression will cost far more than the lives if we fully embrace opening while protecting the vulnerable.  We can’t go back, so most of the damage is already being borne out, but we have an obligation to not make it worse by reading the data as it matures.  Many say it’s callous to “let people die” but that’s missing the point and moving the goal posts.  We have to accept that people are continually going to acquire this virus and a small % will become ill and an even smaller % will die — even if we all stay home and quarantine until we reach herd immunity which would never be truly known when that occurred.  This phenomena of risk is true with car accidents in terms of distance travelled to risk, Cancer, even the flu on a yearly basis.  I don’t like saying COVID 19 is like the flu, because it really is not.  It certainly infects at a higher rate and does result in more death.  The consumption of resources to care for them is different as well.  We had 40 cases in early March and we’re at ~88K to date (through 14 May).  That’s not a typical flu season which, normally would be months long and could get to numbers above this, but not typically.  So, we shouldn’t diminish that COVID-19 is the flu.  
We should direct our testing and care resources to those people who are most vulnerable.  That’s directing our limited resources towards what the data says is the problem. Perhaps if I’m young and immunocompromised, I shouldn’t fully engage in open society until a vaccine or effective therapeutic (or herd immunity is established) is available to lower my personal risk.  Most would not for obvious reasons anyway.  Or if I’m elderly, but living at home I can get cost free delivery of groceries.  That’s perfect world.  But, we can’t just suspend people’s lives by government fiat across the board when the data says that’s not necessary at this time. Perpetuating this lock down on everyone is almost as reckless as not admitting there was not a problem early on.   Going out is a personal decision, but one in which some people will NOT make smart decisions.  People, however, ought to be aware however that they are liable for their actions in which gross negligence is causing infections (I’m thinking the total nut jobs going out with symptoms or frank illness).  Up here, I go out in a mask if I’m in public and certainly in the office.  It’s much more prevalent and data shows that wearing a mask does reduce the chance of infection markedly if both people are wearing and one is infected.  It’s easy to do and while I don’t like it, for now, it’s fine.  
Ophthalmology is particularly vulnerable in this crisis.  We’re in people’s faces in examining them.  Just Google Ophthalmology Slit Lamp and view the images.  Thankfully, I’m not a Dentist, but you get the point.  Prior to this, I saw about 7,000 people in a year and did over 1300 surgeries per year.  I’m busy.  Our busiest Physician saw about 9,000 people last year, but did far less surgery.  Our main office saw >60,000 people last year.  As a group, we did about 6,000 incisional operations (ie not counting lasers).  
I was forced to stop operating on or about 18 March.  Shortly after the decision to stop surgery, we furloughed most our staff as there was no need when we had no patients and the risk to staff wasn’t fully known.  Clinical volume went from full blast to literally 2-3 per Physician per day.   At this time the PPP was in discussion and another “lifeline” was being discussed in the form a Medicare advance.  In essence, the former is a business loan or grant (if you can keep you employees — 100% of them — by mid-June) and the latter is just that — an advance on your usual Medicare earning forwarded to you that must be paid back in a time block or significant interest penalties are accrued.  
I don’t like frankly any of this government “handout,” but I think the PPP was at least designed in a brilliant way for the month’s condition for which it was designed.  I don’t have to tell you how this program can’t work for other industries such as restaurants, but in our case, it likely will work as designed as long as we can keep our employment numbers at 100%, but the problem is that delayed reopening moves the timeline back for patients to return, putting pressure on businesses to make decisions economically in New England.  the PPP also most likely will work for Southern states who, in many respects, are starting to fully embrace opening much more so than up here.  So, in another month, they likely will return to a reasonable enough volume from previous backlogs to take a survivable loss or small profit.  I think New England, due to policies and politics, is going to severely lag and this will result in the program being altered (I’d say possible) or massive layoffs again.  
However, even if in a month’s time people don’t come back to work, it’s a loan with interest and our volume of people needing “routine service” needs to be sufficient to keep the staff we have.  We’re telling staff if you won’t come back, your self terminating and they lose unemployment.  Harsh?  To some, yes, given the schools are closed and they don’t have help for their children.  However, by the program’s rules, we have to have them return to work.  So, to meet the terms of the PPP, we have to take employees furloughed off unemployment with literally no work going on, because people have been scared to go outside to date.  Our clinical volume is off 60%+ and no surgery yet, but slowly growing over the last two weeks since we started going back.  Most of my colleagues in the South, in some states,  have about a 2 week lead on us.  But, it does vary in terms of locality.  We have the PPP covering people though June’s payroll, but I don’t have to tell you what will happen AFTER the PPP ends.  
For us, we operate in Massachusetts.  Economics will worsen more if Governor Baker states we need another 1-2 weeks for ASCs to re-open.  I’m due to return to the Operating Room next week — 20 May.   However, get this: we don’t know if this will be allowed yet.  Reason?  Governor Baker will release a report, Monday at 1:30p, if we’re allowed to re-open. Which, on it’s face is fine.   So, let’s walk through this:  if Monday he says surgery centers can perform Ambulatory Surgery, I’m good.  I’ve set people up per our ASC’s guidance handed down over the past two weeks, including testing every patient, 1 week prior, with self quarantine to surgery.  The time, effort and cost are crazy already.  But here’s the problem:  on Friday, I got an e-mail from the ASC stating our surgery could be pushed back.  They weren’t sure.  This is beyond frustrating because the ASC planned to open it turns out, by flying blind without fully communicating this.  Frankly, there was no communication from the Governor’s administration to the business or the business to us.  There is no lead time.  Overall, I think Baker has been a good executive and has had a calm demeanor and reassuring, but I can not follow his logic in not having his Department of Health co-ordinate with key societies and business leaders about if the Commonwealth can start returning to many business practices.   One could argue that the ASC shouldn’t have offered to open until the Governor decreed and I would say that’s correct.  However, we had little choice because of people waiting to get surgery (can you imagine having one eye done 11 March and having to wait until 20 May for your second eye to be evened up?) and every day lost that we could have been open is a loss of revenue to a business that is threatened with closure, let alone more frustration for people that just want to see better.  It’s a no win.  
In my case, elective surgery for people that can’t see well due to cataract development is close contact by rule and the population served is at-risk.  So, by his words, maybe we’re not going to be able to operate.  That would be misguided.  However, it’s crucial to open ASCs to allow for much needed revenue for ailing practices, surgery centers and for people who, in our case, need surgery to see better who logically aren’t symptomatic.  Hospitals are in the same boat and this is why many are laying off people.  It’s a 1-2 punch.  We had to shut off this service line to save PPE.  Then a surge here never happened like it did in NY, but PPE shortages were prevalent because every state thought “NY is going to happen to me” and for the cases we did have, the burn rate was many time more than usual.   Then, we couldn’t get PPE produced in China because we sold that manufacturing base out long ago.   Trump didn’t help coordinate this and we will be paying for this decision as a costly waste of state resources that maybe the Feds will pick up.  
What another two weeks without surgery?  Well, two months without performing surgery across the nation will lead to far more problems — falls in the elderly leading to death, broken hips, brain bleeds and car accidents as we do go back to more daily travel.  Many are not going to be able to get to an OR who need it due t backlogs and reduced schedule.  And, if you can’t see well, it affects quality of life dramatically.  Not to brag, but studies prove that cataract surgery has the highest $ spent/quality of life score, unequivocally.    We’ll layoff a large amount of our staff as soon as the PPP ends — the magnitude of which will be directly related to patients seen in the office and surgery being done. I worked really hard to contact as many people as I could to start to generate revenue (understand that from the time of service to payment for medical practices averages about 25 days).  And due to new requirements from the surgery center, I can’t do 30 cases in a day as before. I’m limited to 14. 
Like the OR, we’ve also learned that we can’t see as many people in our office like we did previously to try to limit close contact.  So, for instance, we’re removed waiting room chairs, we restrict the number of people in the office at any time.  We can’t double book appointments and see more than about 30 people per day.  When we get to a certain number of people in the building, we tell them to wait in their cars.  So, even moving forward, our business will contract and our take home will be dramatically reduced.   So, not only will anyone having surgery next week not fully pay me until mid late June, I can’t see as many people in the office and I can’t do as many surgeries as I can physically due do to “possible spread” and fear.  This spirals everywhere:  Lower revenues leads to higher overhead and less revenue “available for distribution” from profits (ie what I can take home to live off) which leads to lower consumption and likely termination of services and people employed for the work available.  So, overall, less employed people and across the board with much lower pay.  We can’t afford to pay people for less productivity.   So, tax generation from my colleagues and I that make upside of the top 5% pay for most of the taxes in the country will dramatically worsen both for State and Federal governments.  
Think more globally and long term in medicine. We can’t accept this rate of productivity for these payment rates. This system can not possibly work if you’re coming out of Medical School with 250K+ debt.  That can’t be repaid at a $200K salary/year level before taxes without compromising your deserved lifestyle for 10-15 years further that you’ve already delayed 12+ years.  Worse, our reimbursements have been cut (15% cut in cataract surgery fees this year alone) and, across the board, have not kept up with inflation for many years.  We all know taxes are going up to pay for this over time.  How are these bag holders going to pay for that?
Everything is going to change unless we all change course as soon as possible and realize that the goal can’t and won’t be “no risk.”  All of this will spiral out of control like our food chains.  Some people reading this wouldn’t shed a tear for anyone making >200K/year or more.  I get it.  But, to attract people to put into the work and skill necessary to fulfill these jobs?  Perhaps we’re going to lose out on some really great people no longer choosing this profession.  You’ll think and care more about that when you need it.  I tell people that going into medicine requires a longer, harder time commitment than most other professions.  Most of us in this profession do it without thinking.  That time commitment is a by product of the skill set necessary to achieve the degree.  And we also have to do this at the top of the class to qualify for everything and maintain that excellence for a minimum 12 years beyond high school.  So, the loss of that talent will affect you at 2:00am when you’re asking someone for advice or needing emergent service.  
Nobody cares that LeBron James makes ~$37M/year in his last contract to play basketball.  He has great talent and people pay to see it.  However, just for perspective, I get paid in one year about what he gets paid to play 1 game and falling.  Thats for seeing 7,000 people and performing 1300 surgeries that had a real world tangible benefit to people’s lives.  I’m not here to wax poetic about how much he makes and I do not.  That’s not the point.  It’s to point out that  the reward is not even remotely worth it.  We’ve devalued the things that used to matter.  We use to pay physicians far more than we do now for far less work and far less regulations on our profession.  Now, that’s not to feel sorry for those choices to enter the field.  Frankly, you don’t know until you get here.  These problems do however, have consequences long term and are being borne out.   This could be said for many professions before as well as now and this crisis has finally hit our profession that dodged so many times before.  We kept increasing productivity to make up for revenue shortfalls.   We can’t anymore.   
My concerns are that Physician suicide is real and worsening:  people that can’t obtain Residency slots but have graduated medical school (hint: you can’t get a license to practice medicine without having an internship at least), people in a debt spiral from high cost schools (like many other degrees) and go into less well paying subspecialties, people who succumb over time to a life of unreasonable demand from patients, standards to “always be right”, regulatory burdens on documentation and fear of litigation for complications that can and do happen without “mistakes or errors of judgement”  and last, mental break down.  I’m here to tell you the pressure is immense.  Any slip up — firing, behavioral outburst, malpractice judgement, misdemeanors leads to an unemployable status.  Here’s also another fact:  unlike law, the degree is useless outside of the limited field.  Pharma job?  Nope.  Need bench research.  Most don’t have that.  Admin?  Nope, have to have Admin or MBA.  Would have to go back to school at more cost/time.  About the only job that may be useful would be consulting and that’s really limited in both by scope (ie field you know) and opportunity.  And, you have to actually deliver advice that helps and people will pay for.  Legal is possible, but there isn’t a high need for expert witnesses on a regular basis.  And you’d look like some hack on a traveling schedule.   This is a small speciality.  I doubt you’d look good to your colleagues pointing out their errors.  It’s depressing and leads to people making awful choices if they have a debt spiral OR they obtain self worth from this job and they can’t do it do due to a lack of a job or one that pays the bills.  
Bottom line:  Business will not return to normal operations because people are being conditioned through nightly news and government press conferences its bad and we can’t go out for fear of infection and, as a result are scared to go out.  Some warning is warranted.  It is clear that contact with infected people equals a higher rate of spread.  However, we’ve changed the understanding of this issue from flattening to curve to elimination and we’ve neglected to point out the minor risk to those people under 60-65 that don’t have co-morbidities even if they do get “infected.”  That’s the underlying problem and misguided narrative.  I don’t even know why colleges are not committing to people being back on campus.  I’ll let this play out, but I’m looking to sell my home right now and move south to retire.  I’m genuinely concerned our self imposed actions will lead to a devastating depression that will last 10 years+ to get back to Jan/Feb 20 levels.  Worse is acknowledging that this is an election year and politically, the blood is in the water.  Delay a few more weeks and the economic damage is so profound, Trump is toast.  Open up and tag him for ANY death increase.  It’s no win box.  And, it’s better than the impeachment farce because he can’t pin the blame on others effectively though he’ll try.  The next guy gets all the benefit of the economy improving just like Obama did based on the Bush Administration’s actions during the Financial crisis of 2008.  The joke is that those actions just re-inflated the balloon and I’m not sure about the ability of the Fed to do it again.  Time will tell.  Hopefully, by that time a beer won’t cost me $20 and I can live on what I saved and have a great view of the mountains.  
We won’t do this often, but every now and then it makes sense to do something unique with the anonymous mailbag.
We ended up with nearly 8k words here.
My thanks to all the doctors out there who took the time to share their  perspectives with us and my apologies to those I didn’t feature. I tried to give a representative sample of all opinions from a geographically diverse cross-section of the country.

Written by Clay Travis

Clay Travis is an author, radio show host, lawyer, TV analyst, and the founder of OutKick (formerly known as Outkick the Coverage).
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