They’re NOT lying… they’re just jargonizing?

What is a test?

Up until now there has been only one type of test which is intended to tell us if the person is carrying the virus.  Actually,  the test does  not look for the virus, it looks for a piece of the virus, and to be more accurate, it looks for a piece of what is thought to be the specific virus.    
The virus we are looking at is a part of a large family called coronavirus, which is very wide spread and is the second most common cause of common colds. 
 The test looks for genes that some think is specific to the SARS-C0V-2 virus, but since not all coronaviruses have been studied, it is not certain that the test is detecting is the gene that is specifically from the SARS CoV-2 virus .
We cannot say that the test is as specific as we would like.  
That may be why there is a lot of concerns about FALSELY POSITIVE tests.

Importantly, we assume that when the test is done, it is done correctly; that when the swab was put in someone’s nose or throat that was done correctly, that the swab was labelled correctly, that it was transported correctly, that it was put in the machine correctly, that the machine was working properly, that the result was read correctly and recorded correctly and sent back to the right person.  LOTS of opportunity for error.  There is a lot of evidence that when tests are done in high stress the risk of error rises. 

So we have lots of reasons to be careful (suspect?) of all test results, positive and negative.

What is a case?

The test as developed has a big problem because the laboratory cannot confirm the test result is right because patients can have symptoms, or may not, may be sick or may not.  If there is no marker, can you say for certain that the test result is correct?

To reduce some of the confusion, public health excludes testing people without symptoms.  You cannot get a positive test in a person without symptoms if you don’t test them.   So we know very little about people with a positive test when they have little or no symptoms.  Maybe this is what a CARRIER STATE, or maybe it is a FALSE POSITIVE laboratory error.

If you only test people with symptoms, and you get a positive test, does that mean the symptoms are associated with SARS CoV-2?  Maybe, but maybe not.  False positives are just as possible in people with symptoms as in people without symptoms.

Also, when people with symptoms of cough and sore throat and fever are tested, only about 4 percent are positive.  That seems VERY LOW.  Does that mean when 96 percent of people with fever and cough and a sore throat in the presence of this epidemic have a negative test?  

Either there are many other viruses around, or this is an example of  FALSE NEGATIVE laboratory error.

All this says that at this point we know very little about what test results means, about its sensitivity or specificity or its accuracy.   Should questionable test results decide what is or what is not a case?

What is a "new death count"?

When many people hear the term “new death count” they may understand that to mean a person who recently acquired the virus, got sick and then very sick and then died. 

But the single group that makes up the majority of the “new deaths count” are elder people, the majority over 80 years, mostly frail and living in nursing homes.  They became sick weeks ago, were admitted to hospital, maybe ended up in intensive care with a breathing tube.  They have been kept alive through mechanical support until their body finally gave up and passed away.  So yes, their death occurred today, but in reality it was expected for days or weeks.  Calling this a "new death" is a tad disingenuous, and needs a different classification.
When you hear a public health official say they expect the number of "new deaths" to rise, they are saying there are lots of these folks lying in beds, and one day, their day will come.

So as you listen to the nightly review of COVID-19 statistics, listen carefully and understand what you are being told.  Maybe it is just language confusion,

But maybe not.

Convocation messages

I attended a medical school convocation ceremony this weekend with a about 300 young people transitioning from being medical students to medical graduates.  A lot of positive vibe going on with satisfied students and appropriately proud families and friends.  It was a re-enactment of a tradition that goes back for hundreds of years.  It reminded me of my own convocation ceremony and gave me opportunity to reflect upon how much I had learned in medical school and how little I knew and understood.

It is perhaps a reflection of my last 30 years, but as I heard the occasional presentation by the Associate Dean of the school, I actually listened to what he had to say.  I know that his goal was to be aspirational, but I wanted to give a commentary response.  Fortunately I had enough foresight to keep quiet.  Convocation presentations are not intended for discussion and debate. 

First, I could not agree more with his advisement to the class that society gives physicians the awesome authority by which with their signature on a piece of paper they can provide people with medications, can allow people to either remain off or return to work, and most importantly can spend very large sums of other people’s money (OPM). 

I have always been aware of the close connections between OPM and OPIUM.  Consuming both can provide a certain amount of pleasure and sense of power, but can become dangerously addictive and can lead to ruin.  Extensive over-ordering of tests can become a problematic habit and a danger to Quality. 

Somewhere along the way medical students should learn very early in their careers that ordering every test is a good defensive strategy to prevent being sued.  A better message is that inappropriately excessive tests costs the system a fortune, but does not provide more information; it indeed provides less.  Over-ordering tests leads to diagnostic confusion, false positives, and leads to more repeat tests and more supplemental testing.

Here’s a thought; if docs want to order tests for their own purpose, there should be an insurance code where the charge for the test is billed against the physician, not against the patient.  If you want it just because the information would be “nice to know”, then you should pay for it yourself.   

When students learn that over-ordering is both bad medical practice and poor patient care, and a tragic waste of other people’s money (OPM) they have learned a valuable lesson. 

Unfortunately in the same presentation, the Associate Dean commented that when students came to medical school they were both unknowledgeable (true) and ignorant (maybe a little strong!), but over their 4 years of education they learned not only how to perform medicine, but also how to speak medicine.  They learn the language of medicine that allows them to speak to other colleagues.  They had learned the “special words”.  I agree with him that that is what medical students learn, but I have to disagree with his intent because I understand the term “special words” to mean the same as “jargon”.  

As I have mentioned here before, I do not consider speaking and writing in jargon a good thing, I consider it a potentially dangerous crutch that needs selective use and containment.  We don’t go to school so that we can talk with other doctors.  We go to school that we can communicate and assist patients.  Patients need to understand what we are trying to say and saying it with “special words” does not help.  As pointed out before, today and even more tomorrow, our laboratory test reports and surgical reports, and medical notes are viewed as the proper property of our patients.  It is not the obligation of patients to learn how to understand our “special words”, it is our obligation to create information in a manner and text that people can understand without being trivial. 

Inevitably there will always be some words that need to be part of common dialectic; words like Calcium, and Haemoglobin, Thyroid hormone, and Staphylococcus.  But at the same time when we use these words we need to supplement them with text that allows people to understand our interpretation of results.  This will not be easy.  We have become very comfortable within our own jargon. 

We do spend some time learning how to speak to patients but is not a priority for students in the same way as jargon is.  But is something that our future students will have to learn.  It is a matter of communication and a matter of Quality care.