I can see clearly now, well only sometimes

Infectious Diseases, as so misrepresented by Dr. Gregory House, is a cognitive (thinking) field of Medicine. ID docs diagnose diseases and then treat the ones caused by infection. To be a decent diagnostician, you have to know about non-infectious diseases, which can present similarly to infectious diseases.

When I started making observations in late March b/t Covid and DM and Obesity and then the benefits of HCQ therapy, good friends often asked in a somewhat suspicious, if not accusatory tone, "Why are you seeing what others aren't?". I answered as best I could, that they hadn't yet "cleared the mechanism" and were still being influenced by their biases and preconceptions.

(Btw, I am used to friends and family with no medical experience or education, doubting me now. I mean they are still gonna call me when they get sick, but I am getting used to the doubt, which didn't exist prior to Covid and prior their apparent increased understanding of human pathophysiology, virology, infection control, spread of disease, treatment of disease, RT-qPCR, threshold cycles, ELISA, viral culture, antigen testing, incubation periods, pharmacology, disease presentation, disease prevention, PPE, masks (oh the masks), the difference b/t RNA and DNA, IgG immune response, immunology in general, mucosal immunity, viral carriage, viral shedding, passive immunotherapy, vaccination, vaccine types, epidemiology, history of past pandemics, cell-mediated immunity, QTc intervals, ECGs interpretations, therapeutic response, disease recurrence and response to therapy, prognostic markers, IgM immune response, RNA's stability, chest CT scan interpretation, and other things related to Infectious Disease)

On March 16th, I knew diabetes and obesity were not risk factors for severe viral illness and that they never would be.

By March 19th, I knew I was wrong.

Still, despite knowing I don't see or know everything and consciously trying every day to "clear my mechanism", I don't always succeed.

In late September, a 50 yo black woman from Essex County, NJ came in with subacute pneumonia, meaning symptoms for 2 weeks, no fever, not much cough, but fatigue. She had no other complaints and no significant past medical history. She denied any family history of any significance as well.

Her WBC was normal, but her “Covid panel”, meaning ferritin, D-dimer and LDH, were all elevated, but only mildly elevated. Her chest CT scan looked kind of like Covid but not really. I was confident she didn't have bacterial pneumonia, but gave her antibiotics, including AZM, for that possibility. We gave her HCQ too. Two SARS-CoV-2 RT-PCRs were negative. I thought she got a little better on the HCQ too, but then she started to slowly worsen.

I was pretty sure it was some form of autoimmune pneumonitis. I pressured Pulmonary to bronch her and I started her on steroids. The bronch was, as usual, a waste of time, but the bronch has to be done before a lung biopsy will be done.

She went for lung biopsy the next day. The surgeon texted me and said the frozen path came back as compatible with cancer. I knew that was wrong. I also sent her ANA and some other serologies (cause the Pulmonologist hadn't).

My Dad, who passed away four years ago and was great at eliminating biases, was probably laughing at me from heaven for taking so long to make the diagnosis of Lupus pneumonitis in a black woman in Jersey. Her ANA was 1:2,560 (ANA is measured as a ratio of dilution). The pathology showed an autoimmune process, not cancer. But after she comes off of steroids, this woman will most likely been on HCQ for the rest of her life. >90% of lupus pts are women and black women have a much higher rate of lupus than white women. In Essex County, I have treated many lupus women, admitted with infections of some kind or another, and I have made the diagnosis of lupus in many as well. I cannot remember any lupus pt who wasn't black.

In this case, I made the diagnosis, because I went down the diagnostic algorithm, meaning I methodically did the correct work-up or forced other doctors to do their parts.

I certainly sped up the diagnosis, but still...I should have made it sooner.

Had I not been so affected by my Covid glasses, I would have made the diagnosis soon after admission. Even after I removed those glasses, I still didn’t “see”.

Like Chappy, I tried to "clear the mechanism", but, like a pitcher, who has his curveball, no matter how hard I tried, the ball wasn't breaking and I wasn't effectively clearing my mind and opening up my thinking. Maybe just too fatigued, I don't know.

Because I had no curveball, I had to use my trustworthy fastball, meaning I pushed the methodical work-up, which, eventually and fortunately, worked. Going with one pitch in baseball, you can get people out, it just takes longer (unless your Mariano). Same with this approach.

When I chastised myself to my team for not seeing this diagnosis earlier, they tried to make excuses for me. In bewildered tone I said "Seriously, it took me over a week to think specifically about lupus lung in a middle-age black woman from NJ?!? That simply isn't acceptable" Julie and Daniel supportively pointed out the circumstance and lack of help from other specialties.

I said, "Thanks, and yes, the Covid thing was part of it, but I should be better than that."

I hadn't before seen lupus lung, but I damn sure knew it existed.

I continued, "I don't ever expect other specialties to do their jobs in reaching a diagnosis. I am supposed to do it without them."

My Dad saw things clearer than any doctor or person I have ever seen.

I had to teach myself to recognize my biases. His ability to "see" was natural.

Back in the chaos of March, I was able to "clear the mechanism" and see the obvious in front of me.

We all see things we aren’t looking for and, if they don’t fit with our biases or preconceptions, were rationalize or argue them in our minds away.

It was my Dad's teaching was to, as trite as it sounds, trust your instincts or, more correctly trust your brain.

On March 16th, I knew diabetes and obesity were not risk factors for severe viral illness and that they never would be.

By March 19th, I knew I was wrong.

Back to the question, why did I or do I see things other docs don't?

I guess the answer is – their Dad wasn't named Leon G. Smith, M.D.

His teaching, his trust of his observations, his ability to remove unproven assumptions – those are is what allowed me to see the connection between Covid severity and diabetes and obesity before anyone else, I mean, before everyone else except Ken Lao, the ICU nurse I mentioned.

This approach would probably be best called forced freedom of your mind or listening to your subconscious. And this approach also allowed me to see the benefits of HCQ.

Many docs, good ones, still don't see that very obvious connection between DM and Covid severity, Strangely, everyone now sees the connection between obesity and Covid severity. And everyone is aware of the link between obesity and DM, so not see the connection b/t Covid and DM, you have not only wear glasses, you have wear a mask, which covers your eyes.

Even fewer allow themselves to clearly see the data on HCQ in Covid treatment and prevention. But when you KNOW before analyzing clinical data that HCQ CANNOT work, well, then you shouldn't bother "analyzing data". Doctors, good doctors, have chosen a tribe and their tribalism prevents honest analysis.

Maybe, they will wake up and realize that they are in a cult and that Dr. Fauci or L. Ron Hubbard or whomever isn't the messiah. There have been dozens of published studies showing HCQ works on Covid prevention and treatment. The New England Journal of Medicine and the Lancet have published many articles on HCQ; all show no benefit. Hmmm...what are the odds of that? Of course, NEJM and Lancet each retracted a major article on HCQ, because it was blatantly fraudulent. They then hid and pretended it wasn't their fault at all.

Now, if they can "clear the mechanism", then they have a shot at correctly interpreting them.

They should watch that movie with Chappy.

Or they should quit Medicine.

SMS