Me, snubbing the neighbors. GET OFF MY LAWN!

Me, snubbing the neighbors. GET OFF MY LAWN!

And all the men and women merely players;

They have their exits and their entrances,

And one man in his time plays many parts,

His acts being seven ages. At first, the infant,

Mewling and puking in the nurse’s arms.

Then the whining schoolboy, with his satchel

And shining morning face, creeping like snail

Unwillingly to school. And then the lover,

Sighing like furnace, with a woeful ballad

Made to his mistress’ eyebrow. Then a soldier,

Full of strange oaths and bearded like the pard,

Jealous in honor, sudden and quick in quarrel,

Seeking the bubble reputation

Even in the cannon’s mouth. And then the justice,

In fair round belly with good capon lined,

With eyes severe and beard of formal cut,

Full of wise saws and modern instances;

And so he plays his part. The sixth age shifts

Into the lean and slippered pantaloon,

With spectacles on nose and pouch on side;

His youthful hose, well saved, a world too wide

For his shrunk shank, and his big manly voice,

Turning again toward childish treble, pipes

And whistles in his sound. Last scene of all,

That ends this strange eventful history,

Is second childishness and mere oblivion,

Sans teeth, sans eyes, sans taste, sans everything.

As You Like It, Act II, Scene VII

This summer my wife and I have been transitioning somewhere between stage 5 and 6. My eldest left Tuesday for law school in Boston and my youngest leaves for college next week in LA. So we will soon be empty nesters. As part of the change we have been making a point of going out, to dinners, bars, concerts and theater.

We saw MacBeth performed in a pioneer cemetery, sitting on an old grave as Lady MacBeth practiced aggressive hand hygiene:

Doctor: What is it she does now? Look how she rubs her hands.

Gentlewoman: It is an accustom’d action with her, to seem thus

washing her hands. I have known her continue in this a quarter of an hour.

Lady Macbeth: Yet here’s a spot.

Doctor: Hark, she speaks. I will set down what comes from her, to

satisfy my remembrance the more strongly.

Lady Macbeth: Out, damn’d spot! out, I say! —One; two: why, then ’tis time to do’t.—Hell is murky.—Fie, my lord, fie, a soldier, and afeard? What need we fear who knows it, when none can call our pow’r to accompt?—Yet who would have thought the old man to have had so much blood in him?

No blood borne infections in Scotland.

We saw one of the best productions I have witnessed of Much Ado About Nothing (I enjoyed it more than the Whedon movie) as well as The Complete Works of William Shakespeare (abridged and revised). The latter I highly recommend if it comes your way: Three actors, one dead playwright, and all 37 plays, in under two hours.

Medical theater

CAM Provider: Therein the patient
Must minister to himself.
SBM: Throw physic to the dogs; I’ll none of it.

Theater is odd since it is artifice in a way that movies are not. If they do the play well, you get lost in the moment of the actors, the language, the plot, and the play becomes the thing. You forget that it is all fake. And it can be truly moving. During The Complete Works they briefly abandoned the broad comedy and parody to slide into Act II Scene II of Hamlet with a straight rendition, demonstrating the power and beauty of language of Shakespeare in the hands of skilled actor.

I have of late,—but wherefore I know not,—lost all my mirth, forgone all custom of exercises; and indeed it goes so heavily with my disposition that this goodly frame, the earth, seems to me a sterile promontory; this most excellent canopy, the air, look you, this brave o’erhanging firmament, this majestical roof fretted with golden fire, why, it appears no other thing to me but a foul and pestilent congregation of vapours. What a piece of work is a man! How noble in reason! how infinite in faculty! in form, in moving, how express and admirable! in action how like an angel! in apprehension how like a god! the beauty of the world! the paragon of animals! And yet, to me, what is this quintessence of dust? man delights not me; no, nor woman neither, though, by your smiling, you seem to say so.

Doctors Colquhoun and Novella have referred to acupuncture as theatrical placebo, but as I have watched plays this summer it occurred to me that large swaths of SCAM are Medical Theater. Everyone playing a part, for the moment suspending reason, strutting and fretting their hour upon the stage, believing that the SCAM is the thing, when in fact:

It is a tale

Told by a naturopath, full of sound and fury,

Signifying nothing.

Most of the practice of alternative medicine is delivered to make patients feel like something is happening when in reality it is nothing that occurs. Theater. It will probably stay that way, immune from reality, till Birnam wood. Do come to Dunsinane.

I am in a Bardly mood this week.

Not that theater is without benefit.

Vaccine theater

Sometimes medical theater is understandable. When they took thimerosal out the vaccines, it was not because they needed to for medical reasons. It was medical theater, and necessary medical theater. It was also an interesting experiment, since removing thimerosal from most vaccines has not led to a decline in autism. Not that everyone seems to realize it.

And part of professionalism is participating in medical theater. You have to behave like a medical professional and that behavior is acting like a doctor, whatever that might be. The only time I really feel like a doctor is when I fill a syringe then squirt a little into the air to clear out the syringe. And the powers that be like to mention the theater that increases patient satisfaction. Sitting instead of standing when making rounds, etc, all part of making the patient feel comfortable. As I like to note, when you can fake sincerity you have it made.

Ebola theater

Some aspects of medical theater vex me with inconstant mind. Ebola for example. As infectious diseases go, Ebola is just not that infectious. There are about 23,000,000 people in the three affected countries with 17,000 cases and 6,000 deaths in a year. As epidemics go, it is a slow and small, albeit awful disease and devastating for the countries involved.

We have spent a lot of time and money in preparing for Ebola in our hospital system, and as a general approach to potential infectious diseases I am glad we have invested the resources. Who knows what the next plague will be, but outside of a HCW who spent time in an African Ebola ward, there very little chance an Ebola patient will ever show up in Portland.

That being said, it has been suggested we train quarterly just in case. That is worthless medical theater and akin to planning your retirement based on winning the lottery.

And the powers that be have a program where if a person enters the US from an Ebola country they are ‘assigned’ to one of the hospital systems as an Ebola person of interest, although for what reason I cannot figure out. These are not people who have Ebola risks, just people from Ebola countries. We are supposed to be the contact person should they show up in an ER or have a problem. But the few times a person of interest has visited an ER, have the powers that be have said don’t worry about Ebola, they are not at risk. So why bother to follow them if they are not a real Ebola risk? Medical theater.

Influenza theater

More theater is having HCW’s who refuse the ‘flu vaccine be required to wear a mask.

Don’t get me wrong. If you are a health care provider who refuses to get the ‘flu vaccine I think you are an incompetent dumb ass and should not be allowed in my hospital. Not that I can enforce that opinion.

There has been an initiative to encourage patients to ask if their HCW’s have washed their hands. It is a morally bankrupt idea, since if you are so incompetent at core competencies such as hand hygiene that patients have to remind you to wash your damn hands, you have no business being in health care. It is to my mind akin to airlines having an “it’s ok to ask if the wheels are down when landing” policy.

And patients do not want to ask us to wash our hands. Oddly they expect us to know what the hell we are doing and protect them when they are at their most vulnerable.

Still, I dream of a similar program for influenza vaccination. Patients should ask their HCWs if they have been ‘flu vaccinated and if the answer is no, request another provider, one who is not a dumb ass. It will never happen.

But the question is: will a patient be protected from acquiring influenza from an asymptomatic unvaccinated health care worker if that worker wears a mask (one hopes if they are ill they will not be at work)? No data. The data to support use of masks to prevent ‘flu in the hospital is at best marginal, probably in large part as the main source of influenza exposure is outside the hospital where most people do not wear a mask. If the mask is used to prevent the HCW from acquiring influenza from an infected patient, during flu season any positive effect mask is likely to be lost once the HCW leaves the mask at work and heads out into the ‘flu-infested community

But think about it. Say, as we do, that 80% of your employees are vaccinated against the ‘flu. So 20% are at risk. But at best the vaccine is only 50% effective at preventing the ‘flu. So 40% of the vaccinated are at risk for ‘flu transmission. So if you really wanted to stop the spread of the ‘flu (assuming that masks worked), you would get the most bang for your buck by having the vaccinated workers wear a mask.

I can’t see that an unvaccinated HCW wearing a mask is really going to prevent the ‘flu from spreading. It is too narrow an intervention. Wearing the mask is more of a scarlet ‘I’; a form of shaming that I do not think belongs in the workplace. Prevent them from working in the hospital? You bet, since the data does point to vaccination of HCWs decreasing patient mortality. But if the point of wearing a mask is prevention of influenza spread from HCW to patient, then the only science-based approach would be to mask everyone who walks into the hospital. Otherwise, it is all medical theater, and stupid medical theater at that.

 

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.