The Cat is Out of the Bag

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By Patrick Wagner, MD

America is infected, and you can’t turn that back.  The news we keep hearing about the coronavirus pandemic is constantly changing, often disheartening and as you might suspect, completely dishonest.  The big cliché has become how little we know about this viral infection.  Therefore, I thought it might be good for physicians to pony up, tell the truth, the whole truth, and nothing but the truth, and help get this disease cured.  It might even be that not speaking up could be construed as unethical and not living up to a sworn standard when this is all over, and thus a position of culpability and liability.  Don’t think that those who coerce you are going to stand by you when this is all exposed.  Indeed, they will try to blame you!  Not trying to scare anybody here, just being factual.  The process would be very simple, so doctors should exercise this once in a lifetime opportunity to make it happen.  The American populace is depending on you.

Cure is accomplished by caring about and for the patient once again, even though most physicians are burned out and hate the idea.  The secret is found in the caring and compassionate procedure which gets the ball rolling in any planned therapy offered by doctors to their patients.  It is a procedure that builds trust between the two, and it’s called informed consent.

Having experienced medicine as a general surgeon, it was always mandatory to go over the proposed operation with the patients and have them sign a consent form for the procedure.  It is the law.  The art of informed consent is learned by experience through a surgical residency, and the better you are at it, the more work you are going to get to do.  And if you are a surgeon and you love to operate, you will master the technique and love your chosen vocation all the more, improving on informed consent throughout your career.

What informed consent does is tell patients that you really care about them and you understand the disease process, that you will perform this operation completely focused on them, that the indications are ironclad, and that you are the best surgeon around.  All of this without saying any of it!

When the patient hears that, he or she trusts you and will sign over his or her life to you to help them.  That’s a big deal for the surgeon as well.  It’s quite simply sincere commitment, both ways.

What are the elements of the well-executed informed consent?  First, a discussion, possibly with a sketch, to show where the diseased target organ is.  The symptoms are then defined in simple and understandable language, and thus the first phase of informed consent is satisfied.  It’s called the “rationale” of the procedure, or why the operation is recommended.

The second phase is called the “risk” of the procedure.  The patient understands from the outset that the surgeon must injure him or her to get to the organ involved.  Here is where the art of informed consent is perfected.  Just as getting on an airplane, the possibility exists that it could crash.  So the surgeon becomes very talented, recognizing the patient’s fear, and tenderly plays down those risks via experience and confidence in building a sincere, trustworthy friendship.  It becomes very easy with practice and repetition over time.

The third phase is called the “alternative” to the operation, again discussed very calmly and with caring honesty.  Alternative offers any other options, including not proceeding.  The natural history of any disease defines what happens if medical or surgical therapy is not selected.  It’s the prognosis of not proceeding with treatment.

It might take a bit of time, but the informed consent builds massive trust (itself therapeutic), and if you are good at it you will be blessed with amazingly trusting patients, a very rewarding practice, and a built in referral service!

Let’s look at two extremes in that timing.  First an appendectomy.  It might be that the patient is 14 years old and in the ER with mom and dad.  You’ve examined the youngster and established the diagnosis, and then you carefully define the rationale, risk and alternative with the parents and they sign the consent form.  It takes a little time, but not much once you get good at it. 

The other extreme is a 24 year old man just involved in an automobile crash who is in shock and you are giving blood wide open to keep his blood pressure up.  It doesn’t take much time to tell him, if he’s alert, that you need to get him in that operating room quickly (and you can still do it caringly once you get good at it), while you are rolling the gurney to that operating room.  I guarantee you that patient will give the go-ahead.

The cat is out of the bag.  In other words, America is infected by coronavirus, and we don’t have the ability to reverse that fact.   What’s done is done.  We know a lot about coronavirus.  We know that it is highly contagious or infective.  We know that it is not very harmful physiologically to most people, but it is very, very psychologically affective to many.  This virus causes pathological panic.  Physiologically, everything from asymptomatic carriers, to mildly sick people, to non-harmed and non-infected kids, to the very infrequent really sick person, all are infected.  It is impossible to stop the infection’s spread but it is mandatory to stop the fear or we will die a psychological death. 

We also know that coronavirus attacks  immunocompromised people (for example bone marrow suppressed cancer patients on chemotherapy , or perhaps AIDS patients, or old people in nursing homes with worn out, attenuated, senescent immune systems) and those patients can actually die from this opportunistic disease. 

Note should be made that the cause of death must be determined via pathologic examination of tissue, both gross and microscopic examination (H&E stained slides, at least, by a board certified pathologist) which determines the anatomical diagnosis of death for the medical record.  Nothing shy of the anatomical diagnosis will do.  Anything less is circumstantial and not factual and not proven.  All doctors in America are supposed to know these facts and to practice them.  As stated earlier, doctors are liable in these matters as they should be.  We are presently in a stage of reckoning, and it all comes out in the wash, so beware doctor!

Thus, we know that coronavirus is a weak form of flu and that it is self-limiting.  There is no cure for coronavirus presently.  Now let us see how informed consent executed by caring doctors could help to end this pandemic very rapidly.  Again, we are looking to a higher standard here, and potential culpability for not exercising the sworn obligation of caring.

First, we talk “rationale”, of any proposed intervention or therapy against coronavirus.   In coronavirus, there is either commission of therapy or omission of therapy, as in all diseases.  Thus, if the cat is out of the bag, to distance people and keep them from getting infected is actually harmful.   So in this case, the “alternative” to intervening is omission of therapy, which is not isolating and not wearing masks and not socially distancing and all of the other nonsensical steps being taken by quarantining. Isolation blocks natural immunity and is very dangerous psychologically.  It kills the spirit. It stops natural immunity! 

Common sense comes into play.  If you don’t want to get sick, wash your hands before you eat. Stay home if you are sick, and if you are immunocompromised it is because a doctor has made this diagnosis based on a disease which has caused you to be immunocompromised.  If you think you are immunocompromised, get to the doctor and get a diagnosis.  The doctor will tell you whether you should remain isolated or not.  It is his or her job to do so. 

We doctors learn “natural” or “herd” or “population” immunity in medical school.  We are all tested on our proficiency in knowing it, or we don’t get a license.  The process is called “natural vaccination” and it stops virtually all of the viruses in the coronavirus variety.  We also learn about viruses like polio that can weaken muscles like the diaphragm or muscles in the extremities, and in that case we produced a vaccine and treated the disease.  In that case, the benefit of therapy far outweighed the option of omitting therapy, and the virus was eradicated from the American populace by innovation, the Salk vaccine.  Priority is always key.

This leaves us with “risk”, and if properly described by a caring and trustworthy physician, the patient will understand that risk in this instance means cure and will confidently go back into society, re-establish social maneuvers, stop the masks, cure the fear, get to work, get to school and move forward making America great again. All it takes is caring, compassionate, encouraging and sincere informed consent.  It is the doctor’s responsibility and opportunity now. 

It is your turn, doctor.  Step up and do your job.