Gun violence – a Reckoning

Our California countdown is T-4 days. We fly from Logan to LAX on Friday night.

Recently, I read the Penn Medicine Alumni Magazine article about gun violence in Philadelphia. It made me remember a patient I helped take care of during my medical student trauma surgery rotation at the Hospital of the University of Pennsylvania in February of 2006. I was on a shift in the trauma bay, and the patient was a young African-American man who had been shot in the chest. The surgery resident was putting in a chest tube, and the man – a boy, really – kept shouting “help me, help me, help me.” He was in severe pain, and it was so disturbing to watch.

The cover story, Gun Violence – A Reckoning, addresses the rise in fatal shootings in Philadelphia and nationwide. It calls for an “armistice” as more voices “join in unison” to stop the violence. One powerful voice from the article was that of Dr. Chidinma Nwakanma, assistant professor of Emergency Medicine at the Perelman School of Medicine. Race, gun violence, political neglect – I suggest you read this series. We must stop the shooting, the deaths.

My only quarrel with the series is that it didn’t seem to go far enough. It didn’t get into the political failures of our nation’s leaders, the gun dealers, the NRA, and all of us for our silence and complicity. How can we translate our inertia into action?

I think it requires baby steps. A phone call to your congressperson. Reading up in the issue, for example the work of Professor David Hemenway.

Below, a video from yesterday in Jamaica Plain, the ringing of the First Church bells for the 900,000 COVID dead. Thanks for reading my blog entry! If you enjoyed this blog post, please feel free to leave a reply or share with others. And remember, my website is always free.

https://www.youtube.com/watch?v=v2jknNAS_iY

Tirzepatide 

Our California countdown is at T-5 days.

Recently, I took a look at the new JAMA study, Effect of Subcutaneous Tirzepatide vs Placebo Added to Titrated Insulin Glargine on Glycemic Control in Patients With Type 2 Diabetes – The SURPASS-5 Randomized Clinical Trial, and I have some thoughts.

First, the management of type 2 diabetes is very challenging in the primary care setting because of our fragmented, unequal health care system. Certainly a public health approach, along with a single payer/ Medicare-for-all system would make an enormous difference in the quality of diabetes care. For example, consider the exorbitant price of insulin and difficulty getting continuous glucose monitoring, CGM for many patients.

But say we’re stuck in our current system. Is tirzepatide the answer?

First, consider the delivery system. It’s subcutaneous. That puts it in the category such as insulin and dulaglutide (Trulicity), another Eli Lilly drug. Patients will accept subcutaneous shots, weekly or daily. But they rarely love them.

Now, lets’ think about the trial itself. I always take a hard look at the limitations provided by the authors. They discuss the racial disparities in trial enrollment, which are striking. Can we really extrapolate this drug to our diverse patient populations? Is it appropriate that a trial like this would be published with so few African American and Hispanic/Latino patients in JAMA in 2022?

The patient population was limited in other ways. Patients with psychiatric illness were excluded, along with those with alcohol use disorder. This homogenous patient population is not representative of patients with diabetes treated in many clinical settings. We have large numbers of patients with depression and problematic alcohol use who are also diabetic.

Regarding the results, tirzepatide did reduce HbA1c at week 40. Would it be sustained beyond that duration in a real world setting? Perhaps, but we don’t know.

Finally, the study was funded by Eli Lilly, and there were potential conflicts of interest. This is a huge market, and a large cost for the health care system if it were to be used widely.

In summary, tirzepatide had an effect, but I’m not sure this drug is ready for prime time. A better approach, from my clinical experience, is to focus on nutrition and intensive exercise, and have a low threshold to add CGM along with an insulin pump. I think this approach, along with cognitive behavioral therapy and support groups is much more effective because it minimizes injections and fingersticks and helps patients on the road to healing.

Below, a video from yesterday’s 5K race at Jamaica Pond. I completed it in 25:55. Thanks for reading my blog entry! If you enjoyed this blog post, please feel free to leave a reply or share with others. And remember, my website is always free.

https://www.youtube.com/watch?v=_ED3HFjSBA4&t=14s

COVID-19 as an Endemic Disease

Our California countdown is at T-6 days.

Meanwhile, yesterday I listened to the New England Journal of Medicine audio interview with Drs. Eric Rubin and Lindsay Baden, two of my attendings from my infectious diseases fellowship at Brigham and Women’s Hospital. The podcast was entitled “COVID as an Endemic Disease.”

One point of emphasis from Drs. Rubin and Baden was on COVID diagnostic tests and global scale-up – the variety of tests, their interpretation, and delayed diagnosis. This SARS Cov-2 diagnostics discussion reminded me of the situation with drug-resistant tuberculosis. In Mozambique in 2011, patients and health care workers were experiencing a delayed diagnosis (this occurs in Massachusetts as well – here is one of our papers describing a patient with Isoniazid-resistant tuberculosis).

Xpert and liquid culture (MGIT) for tuberculosis were seldom available in Mozambique a decade ago, and tuberculosis continued to spread. More tests were needed – but they had to be coordinated with the clinics and hospitals. Basic public health infrastructure requires substantial financial commitment. But it isn’t just about money.

Public health and health care leaders have to be collaborating across the globe, or the system will fall apart, as we have seen in COVID. I argue that America needs a single payer/ Medicare-for-all to control COVID and the next infectious threat. Do you agree?

Below, a video where I try to learn Stuff Smith’s version of the song, It’s Wonderful. Thanks for reading my blog entry! If you enjoyed this blog post, please feel free to leave a reply or share with others. And remember, my website is always free.

https://www.youtube.com/watch?v=YJRj7B8feG4

California Countdown: 7 days

So I’m starting to get excited about our trip to Los Angeles – it’s hard to believe we’re going in one week. I’ll believe it when the airplane touches down at LAX.

Here in Boston, yesterday felt a bit like spring, and I enjoyed bumping into Colin Turner on my jog to Jamaica Pond. In our running class at night, we talked about nutrition, cooking, and CSAs, which was delightful.

So now, I’m just trying to make a list of everything I want to pack for our eight days in LA, SF, SD, and TJ.

Passports – crucial to getting in and out of Mexico. Ben Hulley and I are looking forward to a Xolos soccer game in Tijuana, and I want some quality tacos.

Computer– I want to get my ancient MacBook Air checked out at our local computer shop before we go, just to make sure it’s optimized for the trip.

External hard drive– I have a Seagate which is rather old but it should work.

Shur SM57 Microphone and Focusrite Scarlett interface– so I can hook up to my computer and record quality audio.

FM10 Nikon Camera, with 2 extra rolls of film – thanks to Ed Grazda for turning me on to old-fashioned photography.

Canon EOS Rebel Camera – It’s almost 10 years old, but still works well most of the time for video and photos. I also want to bring my mini-tripod.

IPhone and charger and cable to sync up – the packing list is starting to get long

Violin – this is a must, even more than the technology. I could travel with just my violin and phone if need be. Hopefully Ben Sigelman has been practicing on his banjo and electric cello. I know Anna Levitt has been practicing her fiddle.

Notebooks – several, including legal pads, and my music notebook. Don’t forget pens and pencils.

Clothes – as few as possible. Don’t forget swimsuit and floatation device.

Klean kanteen – water bottle. California can be hot.

New running shoes – this needs to happen! My old running shoes are full of holes.

Compass and maps – just in case.

Keys, Wallet. I don’t think I have any Pesos right now so I’ll have to exchange money to get into the Xolos game.

Baseball Cap – I think i’ll go with the Cincinnati Reds hat, although I could also wear extra Joe’s Boston Red Sox cap. We’ll be going to Dodger Stadium so we’ll probably be buying Dodger’s hats. And we might go to the San Francisco Giants, Oakland A’s, and San Diego Padre’s stadiums, so we might be coming back with a bunch of hats. Come to think of it, maybe I won’t wear a hat. I’ll just buy a Dodgers one once we get to LA?

Toothbrush, floss – yes.

Medication – including melatonin for sleep, even though it is efficacy is controversial. A systematic review of meta-analyses of randomized trials showed that melatonin results in a statistically significant but small improvement in sleep latency and total sleep time, but it’s not clear if the effects are clinically meaningful.

Narcan nasal spray – Sadly, you never know when you’ll need to help reverse an opioid overdose

Vaccine card – yes

Gifts – for family/friends. Need to work on this one.

Margo – sadly, no. Our dog will be staying on St. Rose Street with our neighbor / friend Nan, and her dog, Granola.

Below, a video where I try to learn Stuff Smith’s version of the song, Ja-Da. Thanks for reading my blog entry! If you enjoyed this blog post, please feel free to leave a reply or share with others. And remember, my website is always free.

https://www.youtube.com/watch?v=OK_FVNyChpQ&t=299s

California Dreamin’

Eureka! We’re heading to Los Angeles on Friday, February 18th for school vacation after a long Boston winter of cold, and California Dreaming. I first went to California in 1996 for a great trip with my parents and loved walking at Fort Funston, San Francisco; in Sausalito; and in the Marin Highlands in the Redwood forest. I didn’t look seriously at California for college or medical school, but after 9 years on the East Coast, it was time to head west. I settled in at the University of California San Diego for my internal medicine residency in 2008, because of its excellence (it has infectious diseases leaders in the following faculty members – Drs. Robert Schooley, Constance Benson, and Steffanie Strathdee), but also the opportunity to workin Tijuana.

“Tijuana? Isn’t that place a sh__hole, one of my classmates at Penn Med told me before I left.”

“Um… Well, certainly Tijuana has a lot of problems, the main one being the border fence and ways the US Government treats people from Mexico and Central America,” I thought angrily.

So I spent 2008-2011 working in the clinics, wards, and ICUs of UCSD but in my free time going down to Tijuana to collaborate with Dr. Jose Luis Burgos, a Mexican-American physician and UCSD faculty member on his care for the underserved, homeless people who live in the canals next to the border, and in the Zona Norte red light district. When I graduated in 2011 and moved to Mozambique, I held proud the award the chief residents had roasted me with- “Most likely to cross the border.” My nickname? “TJ Phil.”

But then it was time for Mozambique, Atlanta for CDC (and multiple trips to Sub-Saharan Africa and elsewhere), and Boston for ID fellowship.

I came back for a brief trip to San Diego in 2015 for a wedding, and another in 2017 for the ID Week conference, but that’s it. The border region that I loved, the canyons, the desert, the cactus, the ocean, was no longer my home.

Well, now we’re getting for another brief sojourn on the west coast. Our itinerary is on my website. In 8 days we plan to see family in LA; to head up to Monterrey to see Mars Gunja and Ja-Yun Cho and swim in the ocean, and then go to San Francisco and Point Reyes with Ben Sigelman, Maggie Gosselin, Susannah Graves, and Anna Levitt; to come back to San Diego and hopefully catch up with colleagues and friends; and go to Tijuana with my amigo Dr. Ben Hulley to see the Xolos play soccer. If you’re a long lost friend in California or Mexico and want to catch up a bit, please drop me a line.

California Dreamin’ when there’s ice and snow in Boston

Below, a video where I try to learn Miles Davis’s version of the song, Autumn Leaves. Thanks for reading my blog entry! If you enjoyed this blog post, please feel free to leave a reply or share with others. And remember, my website is always free.

https://www.youtube.com/watch?v=dE0RBad9FXc&t=117s

Challenges confront Boston Public Schools amid leadership shakeup

Things are changing in the Boston Public Schools with the impending departure of the superintendent. Of concern is the fate of the most marginalized students within the BPS, especially kids in special education, those who are experiencing homelessness, Black and Brown students, and immigrants. Mayor Michelle Wu has an opportunity to engage the community to hire a superintendent who will support BPS’s most vulnerable students.

As often is the case, I have an unorthodox idea to help Mayor Wu and School Committee Chair Geri Robinson (a friend) with this process. That is, we could have two superintendents for the BPS.

What? Two superintendents? Why?

Well, having co-leaders has been done in many settings, from wilderness hiking groups to co-presidents at several universities. Having co-leaders helps distribute the responsibility and stress. In additional, co-leaders may have very different skill sets. Imagine one co-superintendent of BPS with an extensive background as a teacher, principal, and superintendent of a diverse school district, committed to educational equity and racial justice. Imagine the second co-superintendent as a scientist or physician with a background in public health, infectious diseases, immunology, vaccine development, or aerosol biology. Such a person could be a great complement to the first co-superintendent because it’s clear SARS Cov-2 isn’t going away any time soon. Many more hurdles remain to reduce transmission and improve science literacy in our schools.

The stakes are high. The Boston Public Schools are at a tipping point, and Mayor Wu only has five months to choose a new superintendent, while engaging community members and advocates in the process. Look to Oakland, California where educators are on a hunger strike over school closures. This kind of turmoil could come to Boston as well.

Fear behaves much like an infectious disease. But so does hope. Here’s to co-superintendents for BPS, and to healing and growth in 2022. The Boston school committee will officially begin the search for a new superintendent at its next meeting on February 15.

Below, a video where I try to learn Eric Clapton’s version of the song, Autumn Leaves. Thanks for reading my blog entry! If you enjoyed this blog post, please feel free to leave a reply or share with others. And remember, my website is always free.

https://www.youtube.com/watch?v=j_kYCGgyl8U

Practice Makes Perfect?

I started learning the violin at age 3, and am still studying it at the age of 41. Lately, I have been taking jazz lessons with Rob Flax, a terrific improviser who studied at the New England Conservatory of Music (NEC). I’m learning a lot. However, I’m not certain my playing is improving as fast as it could, mostly because of my lack of self-discipline with practicing. Therefore, I’ve been asking around for advice.

My friend and neighbor Brad Stone is a classical guitarist and teacher, and he told me what he does. He breaks his practice time down into ten minute chunks, and uses a timer. During those chunks he focuses on one thing, such as slowing down a difficult passage and playing it perfectly. He often audio tapes or video records those ten minute chunks. Then, he goes back and listens to them using the “PRR Journal” method. PRR stands for Production, Perception, Response, and it basically means you listen / watch your ten minute chunk critically and then write down what was good, what wasn’t so great, and how you’d improve it in the future. He learned this PRR Journal method from a composer, theorist, and educator at NEC, Paul Burdick – because Brad also studied there.

So that’s my goal. Ten minute chunks, which I will put on my calendar. Then ten minutes to watch and critically appraise my musicality. I’ll put some of them on my Youtube channel. The goal of practicing this way is not perfection, but improvement. Here’s the first one, below.

Thanks for reading! If you enjoyed this blog post, please feel free to leave a reply or share with others. And remember, my blog is always free.

https://www.youtube.com/watch?v=-EtISHn2pr4

Protesting COVID inequities in America and globally

Today, it’s another Moral Monday. On past Moral Mondays I read the names of the COVID dead outside the Massachusetts State House with colleagues, and at home on my Youtube channel. Today I will continue this protest, reading more names and will push a little farther. Here is a video I made calling for health equity.

https://www.youtube.com/watch?v=uQX8-IFb7Ns&feature=youtu.be

Thanks for reading! If you enjoyed this blog post, please feel free to leave a comment or share with others. And remember, my blog is always free.

We Shall Overcome

Structural racism is a public health crisis. News reports this past week about a Neo-Nazi demonstration targeting two members of the Harvard Medical School community, Drs. Michelle Morse and Bram Wispelwey, were distressing. Michelle and I were classmates at the University of Pennsylvania School of Medicine and I have the highest respect for her. We must declare our support for and solidarity with Michelle and Bram, and for fixing America’s broken, inequitable health care system.

I spoke with several people close to the situation today, and I can say one thing for sure – we cannot stay silent. Tomorrow, Sunday, Feb. 6, an event is planned from noon–3 p.m., outside of Brigham and Women’s, which organizers are describing as a peaceful “March for Medical Freedom.” The event is in response to the COVID-19 vaccination requirement for solid organ transplant candidates. As professional colleagues, we must condemn attacks on Drs. Morse and Wispelwey, as well as their colleagues fighting racial inequities. Health care institutions, universities, and government leaders must protect and support innovative thinkers like Drs. Morse and Wispelwey who seek new ways to promote health equity.

We can sing out — We Shall Overcome. This is an important song from the Civil Rights Movement which still rings true today. In dark times, it gives us hope. We can use the arts to push us forward when we want to stay back.

https://www.youtube.com/watch?v=8WhdCP2DGvg