More Disrespect For Primary Care Docs - NEJM Article On PSA Screening

I don't get no respect!

Thanks for that mantra, Rodney Dangerfield. Primary care doctors, regarded as the heart of the health care system by the enlightened, still get no respect from their specialist brethren, and the New England Journal of Medicine editors allow it to continue.

Screening for prostate cancer with a PSA test is a difficult and contentious issue. Opponents have several issues, but I have always gotten the test personally, on the recommendation of my urologist, because we think we can handle the results intelligently, not leaping blindly to unwarranted biopsy and other measures. In short, my urologist Joel is smart, I am smart and a doctor, and we can handle it. Most of the objections center around poor decisions made by those less informed, so we just go ahead and get the test, which has always had a reassuring result. Simple reassurance has its own value.

The NEJM article, Reconsidering Prostate Cancer Mortality -- The Future of PSA Screening, considers what doctors should do if they insist on getting the PSA test. It is here that they stumble into insult. Here's my letter I sent in the NEJM:

The authors of this well-reasoned article perhaps inadvertently impugn the abilities of primary care physicians when they patronize them in searching for an “approach … (that) is simple and easy to remember,” suggesting that they refer the patient when the PSA gets to 10. Specialists are more capable, they imply, so they can pay attention to the rate of increase of the PSA, the age of the patient, and perhaps even order a free PSA and an MRI.

How insulting to generalists! The authors should be reminded that all primary care is not (yet) dispensed by unsupervised PA's at CVS.

It looks to me as though advocates for primary care still have a long way to go.

Budd Shenkin

Reforming the Presidential Pardon - a favorable review

Readers might remember the suggestion (here) that we pass an amendment to the constitution requiring that presidential pardons be cosigned by the Speaker of the House. This reviewer, happily, calls this solution “elegant.” He is so kind!

David Levine and Budd Shenkin on Presidential Pardons

Published on: April 16, 2020 Author: Zach Price
The President’s pardon power has received renewed attention and controversy during the Trump Administration. Those interested in a useful survey of controversial presidential pardons from this administration and others, as well as an interesting proposal for reform, should check out a new article in the Hastings Constitutional Law Quarterly, “Should the Power of Presidential Pardon Be Revised?,” by my colleague Professor David Levine and co-author Dr. Budd Shenkin.
Professor Levine and Dr. Shenkin argue that the pardon power has always carried risks of abuse, as evidenced by many presidential pardons across American history that served to protect presidents and their friends or associates from embarrassing investigations. Salient examples include Ulysses Grant’s pardoning of colleagues involved in the “Whiskey Ring” scandal, Gerald Ford’s pardoning of Richard Nixon, and President George H.W. Bush’s pardoning of some Iran-Contra conspirators.
Professor Levine and Dr. Shenkin argue that risks of abuse are getting worse. They point to President Trump’s various controversial pardons, including those of Arizona Sherriff Joseph “Joe” Arpaio, right-wing pundit Dinesh D’Souza, and author Conrad Black. They also note his promises to pardon others, including federal employees who break laws to build Trump’s border wall, military officers who violate the laws of war, and even Trump himself if necessary to prevent prosecution for official acts.
After considering and rejecting various alternative solutions, Professor Levine and Dr. Shenkin propose an elegant remedy: The Constitution should be amended to require the Speaker of the House’s assent to any presidential pardon. This solution, they argue, would introduce a valuable check on abusive pardons without bogging the pardon process down in bureaucratic rigmarole or imposing conditions on pardons that may prove difficult to enforce. They point out that similar constraints have worked well in some state constitutions.
The proposal is well worth considering. At present, the pardon power gives the president an absolute prerogative that sits uneasily with modern notions of bureaucratic regularity and the rule of law. Pardons are a lightning strike, dispensed from the ruler as a matter of grace with no burden of justification or requirement of consistency across other cases.
Pardons also implicate a pervasive problem of constitutional law and separation of powers: Who will guard the guardians? The pardon places a check on Congress’s power to enact criminal laws, but the pardon power itself is then unchecked (except perhaps by other retaliatory actions on Congress’s part). Imposing a further check, however, risks abuse on the part of the one doing the checking, which could warrant still further checks—and on ad infinitum, with paralyzing effects on governance.
Professor Levine and Dr. Shenkin make a strong case that one further check on the pardon power is warranted in this moment, when political constraints on self-serving presidential pardons seem to have weakened. They recognize that the check they propose could create risks of gamesmanship and hold-ups: a hostile speaker might reject pardons for political reasons or bargain with the president for other pardons in exchange. Professor Levine and Dr. Shenkin make the case that even with these costs the new equilibrium would be preferable to the current one. Anyone interested in the health of the nation should consider their points carefully.
http://sites.uchastings.edu/scholarship-blog/2020/04/16/david-levine-and-budd-shenkin-on-presidential-pardons/

COVID-19 Impels Paradigm Shift In Public Health And Medicine

We all know that a crisis is a terrible thing to waste.  COVID-19 is certainly a major crisis. There will be changes all over the world in medicine, public health, government, financing, social relations, and certainly art. What will those changes be?
Capitalism is a very potent tool to use in conceptualizing what changes are afoot. Thinking like an investor is a great way to envision the future. Nothing like thinking "how could I make money off this” to impel serious effort.
Health and medicine is my field, and it's a little known fact that, besides being a pediatrician, I am also a board certified specialist in preventive medicine, and I am an investor of long standing. So let me just write a short note using that background to opine on changes I see right now stemming from the pandemic.
I think there could well be several paradigm shifts in health care. Think of it first in the very short term. Think of hospitals needing to open up to do “elective” surgery and other traditional services. What do they need? They need to ensure that the operative areas are safe for patients and staff. How to do that? Real time testing - everyone coming in is certified free of virus at that very time. It may mean a nasal swab every day - the Abbott testing system might work for this purpose. Other tests will be developed. As an investor, I would really like to know who's close on this - a small company with a dynamite real time test would be very valuable. 
Now think a little bigger. Won't every company want to do the same thing? Think about going into the stadium and going through the security line. That's the way to think of it, imho. Testing for germs will be more important than testing for knives and guns. Who's going to supply the equipment for the security line testing? That's the company I want to own.

Then let's think about schools as well. Schools are the traditional incubators for winter viruses – want to know who's going to get sick during the winter? Figure out who has kids in school. It seems to me that, when flu season comes up, the winter time, even when COVID-19 has a vaccine and has receded from being a pandemic, we're still going to have the usual culprits circulating, like flu, and maybe new ones. There will be enhanced utilization of flu vaccine, no doubt. But early detection will always be key.

How are we going to detect illness in order to isolate it? Security lines will get old fast. Instead, new technologies will have to emerge – in fact, they're already emerging – that sense signs of illness. Think about wearing a watch that tells you that you are about to get sick, you need to be tested to see what it is. Eric Topol is always all over this kind of thing: 

https://twitter.com/EricTopol/status/1248993495169130496.

In medical care, telehealth will now undoubtedly take off. Outpatient health care providers were already starting to employ telehealth, and now they are all in. I think that very soon more than 50% of doctor visits will be virtual. See here for what Israel is doing:

https://www.youtube.com/watch?v=MkpO5CIk6i8&feature=youtu.be

Telehealth needs all these sensing devices and all the communications. It will be a complete paradigm shift. I want to own those communication and sensing device companies!

Yours for profit in making the world a safer and better place,

Budd Shenkin

Maui and COVID-19

Maui is an island. Maui has control of its borders that would be the envy of many communities on the mainland. Maui is also apparently not overrun with COVID-19. On the other hand, Maui is far from self-sufficient; Maui's economy is tourist-dependent.

What Maui needs is a vision and a plan.

My vision is this: Maui comes to be seen as a haven of health. All we need to do is test, test for current infection and test for past infection. Test, test, test. If we can test, we can control the spread of the virus. We can make Maui CPVID-19 free. Then we can advertise to potential visitors – come to paradise where the days are long and warm, and the island is COVID-19 free.

How can we get to that vision?

First, we need an epidemiologist in charge, someone who really knows what he or she is doing, someone who has experience like that gained by having been a member of the Epidemic Intelligence Service of the CDC, someone who has chased disease, someone who has the executive experience to command a team. Get that person to Maui, give them a job, and give them a $5-10 million budget to get supplies and hire staff.

Then, get the tests, lots of them.

Then, test widely on Maui to find those with the disease, isolate them, find their contacts and test them, and isolate those who are positive. Wipe out the disease.

Then set up testing at the airport. Make it mandatory that everyone who comes on the island gets tested. That way, we can ensure that the island stays COVID-19 free. There will still have to be widespread testing to make sure the disease doesn’t sneak in, but with this regimen, guests can feel relatively safe – probably safer than they would be at home.

I don't know what the time line would be, but I would bet this would be achievable by late fall or certainly winter – peak tourist season.

That's my vision, and I'm sticking with it.

Budd Shenkin

Sweden Vs. USA on COVID-19

From my friend Annika in Stockholm comes this article. Then there is my response, which is really a rebuttal, I guess.

https://www.aier.org/article/what-sweden-has-done-right-on-coronavirus/

What Sweden Has Done Right on Coronavirus

– March 31, 2020

Until last week, only three European countries had still not closed their schools as a result of the coronavirus outbreak. Then followed Britain’s sharp reverse-course and lockdown policy where Prime Minister Boris Johnson finally gave in to pressure, leaving only Iceland and Sweden with a strongly diverging policy.
Iceland, a miniature country that could probably test its entire population in an afternoon should it wish to do so, is a scarcely populated country with fewer inhabitants than Staten Island such that its experience (2 deaths) might not have that much to tell the rest of the world.
On the other hand Sweden might, at about twice the size of Minnesota with roughly twice the number of the North Star State’s inhabitants.
Let me share some observations of the remarkable impact this crisis has had on Swedish society.
All here is definitely not well. Sweden, like most other countries, experiences its fair share of this uncontrolled pandemic. As of Monday night, over 4,000 cases had been confirmed, with the death toll approaching 150 and another 300 in intensive care. In per-capita terms, that’s about the same number of confirmed cases that the CDC reports for the U.S., but with over twice as many dead (I refer anyone interested in the weeds of the statistics to Our World in Data).
Swedish hospitals, businesses and households are facing the same ills everyone else is facing. What’s so striking is that this Scandinavian country seems to deal with its burden with more serenity and pragmatism than elsewhere – no panic or mania; just Work The Problem, People.
Instead of locking people in their homes or spreading fear and mania of various flavors, politicians – and more so scientists and civil servants in charge – have been surprisingly sensible. From officials at press conferences to scientists on prime-time TV, the prevailing notion has not been to shove official rules down a subversive population’s throat or boast about all the marvelous new things My Party did, but to provide the populace with enough information. To present the risks we are facing individually and collectively, and let normal people weigh their own risks and benefits, guided by common sense.
Contrary to the U.S., where President Trump and Governor Cuomo and countless other political figures compete for the attention of their constituents and populace and underlings, the Swedish experience has been one of decentralized decision-makers and arms-length officials calling the shots. So far, there has been very little politicking – very few special interests seem to have pushed their Very Special Interests during these critical times. Instead, politicians have by and large taken a step back and trusted that the responsible agencies – the epidemiologists, the universities, the civil servants, the doctors and nurses and hospital workers who put their lives on the line – have the know-how to do their job and the common sense to act properly.
Folkhälsomyndigheten, its closest American equivalent being the CDC, has simply worked the problem. Their chief epidemiologist, Anders Tegnell, has become a well-recognized face as he’s conducting interviews, press briefings, and organizing what is probably an impressive team for testing and monitoring the best-available data.
Swedish television, both publicly and privately run channels, have professors and WHO scientists every evening answering viewers’ questions, matter-of-factly explaining the latest news and admitting ignorance and uncertainty when appropriate. No presidents bragging or secretaries meddling with business they are wholly unqualified for. The prime minister did address the nation, something Swedish prime ministers almost never do, with a short non-partisan speech about getting through this together.
Dr. Emma Frans of Karolinska, Sweden’s world class medical school, has probably been on TV every night for two weeks straight. Agnes Wold, another media-famed professor the public has taken to heart, shares her advice in most major news outlets. In contrast to Trevor Noah of The Daily Show who now smugly runs his show isolated in his apartment, Skavlan, the most viewed talk show in the Nordics, runs on Friday evenings as usual – but in order to mitigate disease spread it no longer has a studio audience. When Wold visited last week, she didn’t just explain the scientific state of the virus to millions of viewers, but she practiced what she preached by demonstrably sitting about four meters away from her fellow talk show guests. Keep distance, don’t panic.
Many Q&A sessions with experts have included mundane doubts by concerned citizens about whether they should still hold family dinners, get married or visit their elders. In contrast to politicians’ one-size-fits-all restrictions for the number of people allowed to meet in public – Germany and Australia, 2 people; America, 10 people; Britain, no people – Swedish policy-makers and scientists made sure that the public understood the seriousness of the situation, but properly left such decisions to those best able to make them: people themselves.
American politicians of all persuasions have dabbled in things they know very little about: making promises their officials had to correct, botching the testing procedures by pulling regulatory rank to stop workable tests. While Swedish politicians have enacted fiscal and monetary stimulus packages that have been far from perfect (too little, too late, and too much of much too expensive debt packages), they have mostly done the country a service by not interfering.
The few times they have, they have done so prudently. A few weeks ago – lifetimes in this corona era – the government prohibited public events with more than 500 people, clearly communicated not as a fixed limit below which everything was safe, but as a guideline for safety. When that limit was reduced to 50 this weekend – much higher and much later than other countries – it was again presented as a rough limit, exempting private functions like corporate events and commercial activity, leaving final decisions in the hands of individuals.
When the government on the advice of epidemiologists finally closed universities and high schools – primary schools remain open – the relevant minister, pragmatically and matter-of-factly, answered journalists’ questions about what took them so long: the scientists say it probably doesn’t make a difference – and the youngsters are likely to hang about in coffee shops or at each other’s houses anyway, completely thwarting the purpose of the policy.
No political grandstanding, no “I’m the Big Boss,” no typically American swankiness. Just plain old pragmatic, Nordic calmness, letting the system do the work it was set up to do.
When instructed by the relevant public agency, the military built an emergency hospital outside of Stockholm. When hospitals called out for more personnel, regional politicians and the hospitals they are in charge of temporarily waived entry requirements for soon-to-be nurses and doctors, boosting the hospitals’ workforce. Where needed, hospitals have hired back recently-retired health care professionals. And behind the scenes, thousands upon thousands of other health care workers, food delivery services and civil servants do their job splendidly, partly because politicians and regulators are not interfering with their work. The government has made additional fiscal resources available and quickly covered sick pay for vast sways of the population – very easy when your government-debt-to-GDP ratio is 35% – but has not made an arduous public spectacle out of its legislative procedure as did American representatives.
The remarkable behavior and resilience of Swedish society is not limited to the public sector.
Like across the U.S., Swedish vodka companies started making hand sanitizers for distribution to hospitals and the general public. Scania, a major producer of trucks now unable to source components from China, have placed their logistics and distribution teams at the disposal of Getinge, a medtech company churning out ventilators for hospitals all over the world. Toilet paper factories, of which there are plenty in a major exporter of paper products like Sweden, have ensured that toilet paper shortages have been few and far between.
Indeed, Essity, the world’s second largest supplier of toilet paper has ramped up their production and added mask production to assist hospitals. In an example that well illustrates the Work The Problem mentality, Essity’s media relations manager, Henrik Sjöström, tweeted a picture of the company’s delivery trucks and mentioned the 3 million toilet paper rolls one factory churns out every day: “Here at the factory,” he wrote, “we call this special day ‘Tuesday.’” Just keep on working, guys.
Supermarkets (with only very occasional shortages of a handful of items) opened their doors an hour earlier exclusively for people above 70, such that they too can get groceries under comparatively safe circumstances. The demand for food delivery services has absolutely exploded. When the news broke a couple of days ago that Skansen, the iconic zoo outside of Stockholm, was close to bankruptcy for a lack of visitors, thousands of people bought annual passes and stuffed animals from their online shop – and even Venmo-ed their gifts. The manager had expected the government to come to its aid but, as usual, the private sector was there faster.
Like everywhere else, fewer people are seen on the streets of Sweden’s major cities – partly as a result of high school students taking online classes and companies (on public advice) asking their employees to work remotely. Concerned with the survival of their local pubs, cafés and small businesses, healthy Swedes without symptoms have ventured out to support their regulars, maintaining safe distance from others: balancing the need for infectious disease control with economic damage control.
To a certain extent different rules apply: an authoritarian Chinese state can clamp down on its citizens, going to extremities to quarantine infected people; a low-density country is by geography alone much less vulnerable to a disease that spreads by proximity. But Sweden isn’t an authoritarian state that treats its citizens as unruly children. Neither is it a remote and sparsely populated place: its population density is about two-thirds that of the U.S., mirroring America in that most of its population is concentrated in urban areas. Stockholm has the population density of Chicago or Miami and is only slightly less dense than Boston.
Not exactly holed up in their homes, Swedes are out and about, shopping and exercising almost as if nothing was going on – though not entirely so: there’s a new unwritten rule among runners and dog-walkers in my local park. Whenever we pass each other, we keep a good 3-meter distance; people literally walk in wide circles around strangers. Shaking hands is out of the question, and people are comfortably maintaining distance even between neighbors and acquaintances.
Nobody policed this behavior; no politician passed a law or issued a command for it to emerge. Sensible, well-informed, and respectful citizens did so. Nobody drew a line in supermarkets such that people could keep their distance – our natural sense of personal space did that, amplified by a commonly-felt urge to limit risks, but without shutting down commerce or society in the process.
There’s no mayhem, but plenty of fear and anxiety. We don’t know where this is going. This isn’t over, and this isn’t a joke.
The major difference between Sweden and many other places is the trust Swedes place in their institutions, the public agencies tasked specifically with events like this and private enterprise that produce and distribute the goods we need – the employers, factories, and brands that work to see a future beyond corona.
The response of Swedish society has been pretty remarkable: do your part. Help your loved ones and your local business owners. Trust those who know what they’re doing. Be mindful of others – and don’t sacrifice economic well-being at the altar of extreme disease control. Work The Problem, people.

Joakim Book

Joakim Book is a writer, researcher and editor on all things money, finance and financial history. He holds a masters degree from the University of Oxford and has been a visiting scholar at the American Institute for Economic Research in 2018 and 2019. His writings have been featured on RealClearMarkets, ZeroHedge, FT Alphaville, WallStreetWindow and Capitalism Magazine, and he is a frequent writer at Notes On Liberty. His works can be found at www.joakimbook.com and on the blog Life of an Econ Student;

On Thursday, April 2, 2020, Budd Shenkin <buddshenkin@gmail.com> wrote:

Thanks so much for this, Annika. This guy is very opinionated! As you know, I'm predisposed to support Sweden in most everything. But I have to say that this guy has painted the US with a broad brush. The US has done poorly, but I think the weakness is pretty easily pinned on Trump and Trumpists. If Obama, or Bush, or maybe anyone else had been in charge, the difference would have been immense. We can't forget that two years ago Trump disbanded the pandemic response team that Obama had constructed, saying he didn't like the idea of people sitting around when there was no need. The primary contagion is Trump.

It's also true that the American health bureaucracy acted, and continues to act, poorly. I'm not quite sure why this is, because the CDC used to be a great institution that led the world. Organizations decline for many reasons, and I'm not sure why this happened to the CDC. Also the FDA has been exceptionally bureaucratic, but I think you can pin that on the lack of that leadership group that Obama had assembled. Trump is a destroyer, and he has done a very destructive job.

As to political posturing, there are many governors in the US who have done exemplary jobs, mostly Democrats but also some Republicans. Cuomo of New York has become a god.  The contrast to Trump could not be more stark.  I imagine that people abroad don't have the full picture of how bad the Republican party has been throughout the US. I know I must sound very partisan, but the Republican party is the party of destruction and stupidity, bowing down to Trump, and destructive and stupid even before Trump got there.  I don't think you can judge a country comparatively without realizing that.

I doubt the efficacy of the author's reliance on the natural good sense of the people.  People are not naturally all sensible, and you need lots of direction when it comes to public health and habits.  People are practicing social distance, but that's because most people are scared shitless about this vicious virus. It's really helpful that the supermarkets have painted suggested distances to establish in a checkout line.  People don't understand intuitively what 6 feet of distance means.  It's just helpful.  They are scared because of effective transmission of facts by the media and public officials - other than Trump.  There are some stupid states and governors that are behind the times on this, and their states will suffer, like Florida and Mississippi.

As to closing schools - not sure this is the right step, but the idea of not collecting children together is sound.  Anyone with kids knows how they are agents bringing home viruses all the time.  Many are utilizing on-line learning, and that in itself will probably lead to a permanent change -- necessity is the mother of invention.

I think it will be interesting to see what the post-infection changes in government will be. I'm predicting that the health structure will change significantly. Some of this is barring the door after the horse has already escaped from the barn, but some of it will simply be adjusting to the new reality of a world of interconnectedness, and a world beset by ecological change and the mass erasure of many species, with unpredictable results, but the need for increased wariness, and less confidence that things will always remain the same.

Anyway, this guy sounds like a prig.  Far too self-satisfied!  They exist everywhere.

Much love as always,

Budd