David Bensema COVID Conversation This Week in Health IT
May 6, 2020

 – Episode #

Guest Information

Share this clip:

Share on linkedin
Share on twitter
Share on facebook
Share on email

May 5, 2020: As COVID-19 continues to dominate headlines and shape our reality, there are increasingly polarized views. On one hand, some are pushing to return to normal as soon as possible, while on the other, many feel that the current response is the right one and it should continue. As the devastating economic and social consequences come to the fore, how can we move forward to ensure people get back on their feet while still remaining safe? This is a tough, polarizing conversation, and today’s guest, Dr. David Bensema is here to share his insights with us. This discussion captures some of the current sentiments in the US, with Bill asking the questions a concerned patient may ask, and David responding as a physician. We kick off the show by going through what we do know about COVID-19. The novelty of the disease means that information is continually evolving and ideas around transmission and susceptible populations have continued to change. We then move onto why we shouldn’t remove the New York City fatality rate from the total death count. While high density is a factor in transmission, it is not a determining one. This is clear in pockets of infection in unsuspecting places. We then turn our attention to the knock-on effects that COVID-19 has on other health problems. People are understandably emotional and patients have avoided medical care for serious conditions as a result. We talk about the complexity of tackling this emotional response. Finally, we round the show off by discussing a way forward and why collaboration and care will get us through to the other side. Be sure to tune in today!

Key Points From This Episode:

  • Some of the concrete facts that we know about COVID-19 at this point.
  • Conditions that need to be met before mass gatherings such as sports games can resume.
  • Learn more about some of the problems with current testing.
  • Why removing the high New York fatality rate doesn’t decrease the severity of the pandemic.
  • The importance of finding the balance between risk mitigation and elimination.
  • Is there a possibility of designating hospitals as ‘sanitariums?’ We find out.
  • The impact that shutting down has on screening for other diseases like cancer and diabetes.
  • A case for contact tracing and testing despite containment being a lost battle.
  • Getting to the other side: What it takes to get to herd immunity.

A Skeptics Conversation with a Physician Around COVID-19

Want to tune in on your favorite listening platform? Don't forget to subscribe!

Thank You to Our Show Sponsors

Related Content

Amplify great thinking to propel healthcare forward and raise up the next generation of health leaders.

© Copyright 2021 Health Lyrics All rights reserved

A Skeptics Conversation with a Physician Around COVID-19

Episode 242: Transcript – May 5, 2020

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

[0:00:04.8] BR: Welcome to This Week in Health, where we amplify great thinking to propel healthcare forward.

My name is Bill Russell, healthcare, CIO, coach and creator of This Week in Health IT, a set of podcasts, videos and collaboration events, dedicated to developing the next generation of health leaders.

Have you missed our live show? It is only available on our YouTube channel. What a fantastic conversation we had with Drex DeFord, David Muntz, Sue Schade, around what’s next in health IT. You can view it on our website with our new menu item, appropriately named ‘Live.’ Or just jump over to the YouTube channel. While you’re at it, you might as well subscribe to our YouTube channel and click on ‘get notifications’ to get access to a bunch of content only available on our YouTube channel. Live will be a new monthly feature only available on YouTube. How many times did I say YouTube in that paragraph? Subscribe to YouTube. We have some great stuff over there.

This episode and every episode since we started the COVID-19 series has been sponsored by Sirius Healthcare. They reached out to me to see how we might partner during this time and that is how we’ve been able to support producing daily shows. Special thanks to Sirius for supporting the show’s efforts during the crisis.

Now, on to today’s show.

[0:01:14.0] BR: All right. Today, we’re joined by Dr. David Bensema, friend and advisor to the show. Good morning, David, and welcome back to the show.

[0:01:20.3] DB: Good morning, Bill. Thank you for having me.

[0:01:22.7] BR: Well, I was trying to think, who could I have this interest – I had this idea for a show, I was trying to figure out who I could have on the show to actually do this. You are the perfect one to do this. What we’re going to try to do is something a little different, a little off the track of health IT. We’re going to do a little point-counterpoint and try to capture the current sentiment of the discussion in the US.

What I’m picturing is a conversation between a patient who just lost his job and wants to go back to work, represented by me and his physician represented by you. We’re going to do a little point-counterpoint. This is going to be an imperfect conversation from two imperfect people as we explore really the handling of the pandemic. I would just ask people to give us a little grace here. Don’t hate the messengers from either side.

Really consider the show as a time capsule for the conversations that are going on all over the country. I actually went out and hit social media, collected a bunch of the stuff straight from social media. I called some people that I know were not happy with the shelter in place and whatnot and I said, “All right, if you were sitting across from a doctor, what questions would you ask?” I actually did a fair amount of research to get questions, word for word, from the people who were asking them, to try to make this as authentic as possible.

Let’s start with the most obvious question, which is what do we really know about COVID-19 at this point, things around transmission rate and lethality and those kinds of things?

[0:02:54.9] DB: Yeah. I think one of the things we definitely know is how little we know. If we have the humility to recognize that, then we can join together to move forward, instead of polarizing. What we do know is that it is something not seen before, so none of us had immunity. That makes it a unique setting. Influenza each year, we have some carryover immunity, not even counting vaccines. We have some immunity within the population that helps to mitigate it. We don’t have that.

The other thing that we know is that it is highly, highly transmissible through droplets, so close contact, respiration, coughing all help to transmit it. We also know it can transfer from fomite, not as effectively as by droplet transmission, but still fomites, inanimate objects; it can live on those for periods of times and we’ve seen that the studies show it hangs out longer on some of the hard surfaces than we thought it would.

The other thing that we know about it is it has a predilection for susceptible populations. We’ve all heard who the susceptible populations are. One of the interesting add-ons to that is people who are exercising aggressively who get exposed during that time actually have a propensity towards the pneumonia, because their inspiration, their volume of air movement bypasses the normal upper respiratory and upper bronchial immuno-response and lets the virus get right to the alveoli, air sacs in the lungs and cause disease.

We’re seeing that in some young, highly trained athletes. That’s an interesting thing that’s making us more aware that this is not as discriminatory a virus as we would have liked to have thought that, “Oh, it’s only our very aged and multi-illness patients.” It is a large segment of the population and now we’re looking at some of the Kawasaki-like syndrome in children and some of the other manifestations in children and we’re realizing again, none of us have immunity. All of us are going to have some form of a response and we’re getting a better picture of what that breadth of response can be. Now we have to fine-tune understanding even more which populations are at risk.

[0:05:32.2] BR: All right. Here’s the interesting thing. I have questions here that are easier, harder. I’m just going to go through them. Actually, since you brought up exercise and those kinds of things – I approach this from two perspectives. One is, the question is when are we going to be able to go to a crowded stadium, like a sports event, or a concert in the future? That’s one question. But the second would be is it safe for people to participate in a baseball game, if what you just described is one of the potential outcomes?

[0:06:12.2] DB: Yeah. As far as when do we get to go back to crowded stadium, either a truly effective vaccine with a high penetration of immunization in the population, or second, the population at large has had enough disease penetration that we have over 60% of the population having had the virus and then having immunity, if indeed it proves to provide any immunity.

They’re still trying to figure out, do we have long-term immunity after recovery from the virus? When either of those conditions is met, then we can crowd the stadiums. In terms of is there a risk for people in sports, baseball, a lot less than others, because the proximities and contacts are generally reduced? Only times are at tagging and those don’t happen that often, but it’s still a possibility.

I would think more soccer, or football to the rest of the world. Soccer, you’re in close proximity frequently and respiring at a high rate. I would think that would be very dangerous. Basketball, likewise, very dangerous. Hear the NBA wants to come back. Is that going to be safe? I don’t know. I don’t think so.

[0:07:33.9] BR: Yeah. Well, I don’t want to get stuck on that question, because there’s so many questions here. I was going to say, if we do testing and everybody in the game is COVID-free, or not infectious at that point, is that game safe? Should we consider it safe?

[0:07:55.0] DB: It is a lot safer than if you didn’t do testing and allowed just everyone there and maybe had some folks who were asymptomatically infected. However, my concern is that the tests that are so far available still don’t meet what we used to consider to be the threshold for sensitivity and specificity. The false negative rate and the false positive rates are really quite high.

False positives, fine. You’re going to exclude them from the game. That’s a problem for the athlete, but it saves the others. False negatives is a real problem. When you have 8% false negatives being a “good test” currently, that’s still too high to really provide mitigation.

[0:08:40.9] BR: All right. Yeah. Again, people don’t shoot the messenger. I’m just pulling this stuff off of social media and different things that I’ve read. 68,000 deaths as of this morning. 30,000 of them are in and around New York City. The question really is if you take those numbers out, if you take the New York City numbers out of the total, don’t we just have a bad flu season? Is this a big city mass transportation, high-rise, elevator-centric problem living in close proximity problem? Because when you look at some of the other more spread out cities, like LA, you only have 1,200 deaths. 57 deaths in Orange County, even though there’s millions of people there.

Those are two places – keep in mind that they have an awful lot of travel between China and the West Coast. Do we have just a close proximity living problem, New York and other really close proximity living issue?

[0:09:39.9] DB: We don’t. We have a worsening in close proximity, but we have the problem of people who work in roles, where they cannot distance themselves, protect themselves, so it can be in a small area. It is a crowding, or a proximity issue, but it can happen in a lot of places that you would not anticipate.

North Dakota is one of the ones the news agencies are going to, because the meat packing plant up there and the issues they had. Yes, we would see a lot less numbers if New York was taken out of the equation. You’ve got to believe that New York is – Chicago, Detroit. Yeah, LA is spread out. San Francisco is not as much spread out. You still have some cities at significant risk. Then you’ve got areas where you could get pockets of infection as we saw in North Dakota and in a smaller population, have pretty high percentage of case incidents.

[0:10:48.3] BR: Yeah. I live in a community. This is – I talked to somebody yesterday. This is essentially the question they gave me. We live in the same community. I live in a community of about a 1,000 people in Florida. It’s a community with a fair amount of retirees. Given the transmission rates and all the things we know, there’s 600 confirmed cases in our county. We have proximity to large cities here in Florida. It’s not like we’re that far away from Orlando, Tampa and Miami.

The fact is we never closed the golf course. The tennis courts are still open. Pickleball is still open. FedEx and Amazon might as well have a racetrack out here. Their trucks are going through the community almost on an hourly basis, as well as contractors are still going in and out of houses and doing work on a regular basis. I’m going to really channel my stats teacher here in college and he would say, “What is the probability that no one in this community has COVID and that no one has died from COVID?” It doesn’t seem probable.

[0:11:50.8] DB: Yeah. That probability approaches zero. My wife and I were recently in a different location. In that location, it’s a stable population of about 3,000 and itinerant population of 1,500. And had not heard of any cases, until late in the stay. Then one of the church members at the Presbyterian church was reported to have succumbed. Where did that case come from? Was it imported to this isolated area, or was it – is there a population with asymptomatic disease in the area? We don’t know. Yeah, it can pop up anywhere. The likelihood that you’re in a community that has not seen at least a case is slim to none.

[0:12:44.9] BR: Yeah. You would think we’d see something, right? I mean, this is an older community. Somebody would be getting sick. Somebody would go into the hospital, or something. Essentially, what the community has said is once we have a confirmed case, we will change behaviors. Until we have a confirmed case – They put social distancing and other things in place, but they haven’t shut down those activities, but they say, “The minute we have one, we’re going to shut down those activities.” You would think we’d have something. Anyway.

[0:13:16.7] DB: Yeah. It’s a tough one. Like I said in the community, where we were – we thought that it was totally isolated, protected and wasn’t going to have a case and then it did. Then the question is did you take the – by having the activities, did you take the Trojan Horse into the city wall and say, “We’re going to push it out once we prove there’s Trojans in it?” The damage might be done if you wait for it in a population of senior citizens.

[0:13:48.8] BR: This question is coming up more and more, which is we seem to be measuring this disease based on cases, not on deaths anymore. We talk about flattening the curve and that was the whole thing, we’re going to flatten the curve. Now we’re getting on the other side and people feel the goalposts have moved. The question really is do we track a flu based on cases, or do we measure the flu based on again, how lethal it is and how many deaths come about from it?

[0:14:15.9] DB: Yeah. With the influenza seasons, we always look at the total number of infected, 29 million, etc. Then we look at the deaths, 30,000 average per year. We track that and yet, we’ve never responded as strongly. We in fact have inadequately responded to influenza over the years, because we really could mitigate that more with better immunization, since we do have vaccines for it. And better hand washing, which now maybe we’re all good at 20-second hand washings.

Our flu seasons could have been better than they’ve been and we’ve been rather cavalier as a nation, but also as a world about influenza, because it’s been around. We’re reacting really strongly to this, it’s new. There’s some good reasons to react strongly. But maybe there’s some overreaction. That balance between mitigation and elimination of risk has to be struck. We cannot eliminate all risk in life. We can mitigate. How much mitigation is tolerable and sustainable? That’s an argument for a lot of folks smarter than me and a lot of folks who understand the economics better than I do. You do have to strike a balance at some point.

[0:15:34.2] BR: Yeah. That’s where we’re going to go next. This question is actually from me. I spoke to a health system that has their OR functioning at about 50%, losing a fair amount of money every month and there’s no option for them to really reopen it at full capacity due to government restrictions and other things that they have to get through. The reality is they have one positive COVID case at the hospital. We’re in the process of bankrupting hospitals for one case of COVID. Does that really make sense?

[0:16:07.1] DB: Yeah. It doesn’t and it does.

[0:16:11.2] BR: It doesn’t until it does.

[0:16:13.2] DB: Yeah, it doesn’t in that that case makes a very good argument for let’s go business as usual and survive, so that we can take care of all these other things that we’re currently ignoring and pushing down the way, because we’re going to see cancer diagnoses rates etc., spike post-COVID.

But it does make sense, because we were not prepared to manage this and because of the structure of our healthcare system, where it is a competitive environment. If you have four hospitals in a community, none of the four from different systems is going to jump forward and say, “Hey, make me the COVID hospital. We’ll take all the COVID cases. Triage them elsewhere, dump them on us, we’ll shut down everything and you guys go.” Well, you could do that and you would have thought it might have happened in Italy, because Italy has a national system and regionalized hospitals and they didn’t have it prepared.

To go forward, I think we’re going to have to think about can we designate places to be the infectious disease, almost back to the sanitarium days, except for when they’re not sanitariums, they have to be fully functioning hospitals. The rest of us support that hospital that serves as the “sanitarium,” so, they can be back on their feet when the crisis is over. That’s, I think, going to be something that policy makers are going to really have to discuss is, “How do we restructure our health system and our utilization of bricks and mortar resources in the US to allow us to respond to something like this without this draconian shutting down of every single site, to the impairment?” Not only of their financial viability, but to the impairment of the population.

People not getting screened for cancers, not getting screened for diabetes, not getting screened for cholesterol. You saw the numbers that came out in New York, 68% on some things and 95% reduction in screening in other areas, because they’re fully engaged with COVID.

[0:18:26.8] BR: Again, some of these I struggle to even read, because I know that people are going to have shudder when I read them. Essentially, we shut down the economy, 30 million people have lost their jobs, 228 health systems have furloughed employees. We have the USA Today talking about the hundreds of rural hospitals that will likely just close and cease to exist. We’ve sent people home and told them, they really can’t go back to work. We’ve really created a petri dish for domestic abuse, depression, mental health issues, as well as some of the things you’re talking about. We’re not doing screenings. There stories now of people literally having strokes at home, because they’re afraid of going into the hospital and getting COVID. Is there a way to do this, where we’re not creating the significant problems on the other side of this?

[0:19:23.5] DB: Yeah. Again, unbelievably complex. I used to talk about complicated was a internal combustion engine. It’s a lot of parts and a lot of things. An individual could actually learn to take apart and put back together an internal combustion engine and know how it works. One person could do that. No one person can deal with a complex system. I think that complexity means the conversations are going to have to be carried out around how do we help the system to move forward, restructure so that we don’t have to shut everything down in the future and reduce some of the anxiety-provoking and sensationalizing that we’ve seen across media in every direction?

If you show us only the worst and you show us scary, scary things about hospitals and we see the Elmhurst Hospital over and over again, I’m not going into that hospital if I’m a well patient, otherwise. Yet, we have to have people going to hospitals. It is much more dangerous to stay at home with some facial weakness and slurring a speech of than to go to a hospital.

Intellectually, we know that. But now we’re at an emotional state. We have to help people come back to a less emotional response. That’s really hard. But we have to be able to say, “Yes, this is new, but no, this is not different than other things we have faced and it does not eliminate all the other series health issues that we should be attending to.” How we do that? That’s like I said, incredibly complex. I think the AMA is joining in the conversation quite well. I think the other organized medical groups are. I think a number of our states, state leaderships are.

We need to have the conversation and unfortunately in the midst of an epidemic, it’s very hard to get people to have reasoned conversations. We are making decisions right now that we would never make at other times, whether it’s for patient privacy, or for accepting tests that are inadequate. We just wouldn’t do some of these things in normal times. When we get to a point where we can take a breath, the conversations have to continue. Unfortunately, we have a history of going – got through that and we move forward.

[0:21:55.2] BR: I’m going to have two questions. Thanks for doing this. I realize there’s no doctor-patient visit where you’re going to talk a half hour with these kinds of questions coming at you, so I appreciate you –

[0:22:06.1] DB: Actually, you’d be amazed.

[0:22:07.7] BR: Really?

[0:22:09.0] DB: Actually, you’d be amazed.

[0:22:10.9] BR: This is pretty normal?

[0:22:12.7] DB: It’s pretty normal. That’s why my CMA was always at the door knocking saying, “Dr. Bensema, you have a phone call,” just to try to get me to cut off.

[0:22:22.3] BR: All right. Let me know when they knock on the door over there.

Let’s talk, contact racing and testing seems to be the playbook that the medical community is throwing around and the only rational approach for containing the virus. Actually, that’s very bipartisan, the contact tracing, testing. The question really is with a million confirmed cases, isn’t containment a lost battle already? Why would I give up any semblance of privacy for a cause that is lost to begin with?

[0:22:55.8] DB: Yeah. Containment is already a lost battle. You’re right. The reality is if you flatten the curve and in fact, can get it to start to decrease a little bit, contact tracing is what helps you prevent the spikes on the go forward. I think contact tracing has a real place. If we were in New Zealand, it’d be a little more obvious of a case. They’ve supposedly eradicated new infections at this point. 

If they see something, then contact tracing would really help them to contain. Even with a million confirmed cases, you can contain further spread by contact tracing and being able to get testing out and then quarantine those who have been exposed and treat those who’ve been test positive, treat which is currently only supportive treatment, right? We don’t have any actual treatment. Remdesivir had some promise, but there’s a lot of questions about how effective that is.

Contact tracing is a way to keep the spikes from coming, control the resurgences that we now anticipate are going to continue over two years, or until we have an effective vaccine that is highly penetrated.

[0:24:25.4] BR: All right, so you said two years, which leads to the final question, which is we’re saying terms as a society now that we didn’t even know back four months ago, which is herd immunity. We hear this whole concept of the only way to get to the other side of this is through it, right? To get enough of the population that has either recovered, or has some semblance of the antibodies built up within them. There’s a couple ways to do that. I mean, you have the now famous, I guess, Sweden is heading through it – They haven’t closed their schools. They’re practicing social distancing, but they’re doing it at a different level than most others. They’re saying, “We’re going to get to the other side of this.” I don’t think they’re publicly saying that, but it would appear that that’s their strategy.

The other side of this in the US is we keep hearing a year and a half until we have a vaccination. I hear the word two years. I hear a year and a half till we have a vaccination. I hear the only way through this is herd immunity. I go, “Are you kidding me? Are we going to live like this for the next two years?” Is that even possible? I’m not sure that’s the question. The question for you is is that the case? Is the only way through this, that enough of the community builds up an immunity and what does the path look like to get from here to a point where we have enough immunity built up within our society?

[0:25:55.3] DB: If you go the herd route without a vaccine, it looks like the total number of deaths that was originally projected and that’s in the millions, 1 to 2 million deaths across the US. You could get to herd immunity. The question there and the one I don’t have an answer to and I haven’t seen an answer in the literature yet is having gotten through that and essentially, sacrificed that many individuals in our population to get there, would you actually have immunity? We don’t know that yet. That’s a huge question out there to be answered. Does having had the infection actually grant immunity for an individual?

Then the next part is can you sustain this for 18 months? I think, because we have such variable approaches, we’re going to continue to have the huge amount of contention. I think change, facilitation, I always hate the word change management, because that still implies that I’m controlling you. But change facilitation, me helping others to understand that simply wearing a mask when out in public and keeping social distance can allow us to get back to a lot of activities, can allow us to restart the economy, putting in place some of the barriers, etc., at workplaces to protect workers can allow us to get back there. I think that’s how you get through the 18 months is with those measures, recognizing they’re imperfect and that’s where contact tracing then comes in, so you can have some further mitigation behind that.

The real question is that’s expensive. That daily cleaning in everyone’s office and everyone’s store, that’s expensive. PPE, expensive. Those are added costs of doing business at a time when you’re making less revenue. How do you get through that economically? I think those are big questions. Like I said earlier, it’s going to take a lot of folks a lot smarter than me, but with a calm voice and with a real desire to help and a real desire to engage everyone in helping, because I don’t think this is something you get through with directives, or with I know better than you, you do what I say type approach. Or we’re going to just stick our head in the sand and it’s going to go away approach. Neither of those works. How do we engage each other and really appeal to our better angels to do what’s best for one another? Golden rule still applies.

[0:28:46.7] BR: Yeah, you know, as is usually the case with you and I. We’re going to end this episode, because it’s coming up on the max that we like to do for an episode. But you and I are probably going to talk for another half hour on this topic. I really appreciate your time today and talking through this.

As part of the prep, I had to go out on social media and read this, just read the social media posts. It’s brutal. I mean, people are talking, but no one’s really listening. We’ve set up sides on this. On one side, you trust in science. On the other side, I guess if you don’t trust in science, you’re just – you’re I don’t know, ignorant. The social media posts almost come off as that. It’s so divisive at this point and it makes the situation that much harder to try to get a cohesive strategy across the board.

It’s impossible to answer when all the planes are going to be back in the air and when I’m going to feel safe getting on a fully packed plane, or when I’m going to go to the next baseball game and sit in a crowded stadium. Those are impossible things and those are probably the last things we’re going to see in this. On the flip side, I feel the pain of some of these social media posts. I mean, just the, “I’ve been furloughed. Do you see a future where I get brought back?” We don’t have answers right now for that, but I wish we would at least show some empathy as we’re trying to explain the seriousness of the disease and the potential ramifications of just ignoring the medical community on some of these things. We can find a path through, as long as we’re going to talk and listen to each other. 

David, thanks again for your time. I really appreciate it.

[0:30:44.4] DB: Thank you, Bill. Appreciate it. Thanks for having me.

[0:30:47.4] BR: That’s all for this week. Special thanks to our sponsors, VMware, StarBridge Advisors, Galen Healthcare, Health Lyrics, Sirius Healthcare and Pro Talent Advisors for choosing to invest in developing the next generation of health leaders.

If you want to support the fastest growing podcast in the health IT space, the best way to do that is to share it with a peer. Send an e-mail and let them know that you value and you are getting value out of the show. Also, don’t forget to subscribe to our YouTube channel while you’re at it. Please check back often as we will continue to drop shows, until we get through this pandemic together.

Thanks for listening. That’s all for now.

Play Video