Once a year I give a lecture to the 2d year medical students on humanizing intensive care. It's fun to be with these bright young people moving toward careers as physicians. One asked me an interesting and important question that seems like it's worth reflection.
Specifically, how do we engage people in positive and respectful ways if we don't have an authentic connection with the patient/family member? We know from RCTs that rote condolence letters after a death seem to raise and then disappoint expectations of intimacy, so how do we
support people without being ingenuine (and/or raising expectations we can't meet)? These questions resonate especially loudly in our modern cultural moment where authenticity is prized, and our radar is tuned to detect inauthenticity, especially among those with power.
This is a hard set of questions, so any answer will be partial and potentially misleading. But a few things do seem secure. First, patients and their families are in crisis and in urgent need of support. It doesn't feel fair to me to say that they can only have human support if
the clinician's mental/emotional state is resonant with theirs. If we have to scramble to be kind, then we should scramble. We can't make them wait to be treated decently until all the clinicians feel an authentic connection to them. Second, building this authenticity requires
steps into the dark. I'm not a partisan Aristotelian, but I think he's onto something with this notion that virtue begets virtue, that living in particular ways makes particular emotional states more likely, more fitting. You can call it "fake it till you make it" if you want to,
but you could as easily talk about embodied cognition or the mind-body interface. We think with our bodies as much as we think with our brains, and being kind and respectful to a distressed patient can train us to feel that kindness as we act it out. So, as long as you aren't
trying to manipulate someone, it's fine to be kind even when it's not born of authentic feelings of kindness. Because it's part of our training. You can't do a central line well the first time, but you don't let that stop you from trying (with appropriate guardrails).
Third, my sense is that the practice of what I call "warm curiosity" can be a helpful pathway into authentic connection. The Anglican theologian Tom Wright would place this into what he calls the epistemology of love, but this doesn't require a particular theological commitment.
What I mean is a wondering about how a person works that is open to the possibility that the person brings a world into being. It's not the impersonal curiosity that builds new transistors or discovers new particles, although there is kinship there too. It's curiosity in the
hopes of learning more about the world writ large and more about this particular person. There are so many stories waiting to be told; just a question or two can get them moving. Asking about body art or nail polish or favorite hobbies or hometowns can give them an opening
to do what normal human beings do (they share stories with each other), to be heard and seen as more than a patient, and to identify areas of shared interest or enthusiasm. So that went on longer than I meant, but my takehome is: focus more on warm curiosity than on your
authenticity. More often than not in my experience, you'll achieve both aims (supporting the vulnerable patient in need of your support AND finding that your warmth becomes authentic over time).

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More from @DrSamuelBrown

2 Oct
The letter from the treating physician for the US president is emblematic of “VIP medicine”. Almost none of it is a good idea even on its own, and no one has a clue what happens when you throw all these therapies together in one giant bag of too much.
Monoclonal antibodies (not polyclonal antibodies, as the letter indicates) are a promising therapy and we have two very early hints from premature soft reports. So that’s outstripping the evidence, but it’s not crazy.The vitamin D and famotidine are crazy town,
There’s no good evidence for zinc, and the letter does not even mention remdesivir, which (admitting that critics are skeptical of a massive effect), I think does have reasonable evidence for moderate effectiveness. The trials of aspirin are just getting underway.
Read 5 tweets
27 Sep
I’ve been trying to support the restaurant industry better lately. The thing that strikes me is what appears to be widely held misconceptions about how to prevent spread. I think they’re used to Salmonella and pathogenic E. coli. So the scrub down the surfaces a lot.
But that’s not how sars2 is transmitted (you should still keep surfaces clean because it’s not like Salmonella died of COVID; plus there’s some small risk for COVID transmission associated with contamination of shared surfaces). It’s transmitted by being near people w/o mask
and eye covering. During curbside contactless pickup today, staff rushed up to me with their mask under their chin loudly explaining to me how clean the kitchen was. She was clearly trying to do the right thing, clearly scared of COVID and clearly not being safe about COVID.
Read 5 tweets
25 Sep
We're all a bit worried about the two neurological disorders seen in the AstraZeneca vaccine trial. In the media, one is being called multiple sclerosis; the other is being called transverse myelitis. These diseases can happen spontaneously, can happen as a result of a viral
infection (we think) and could possibly be an immune response to a vaccine. With the whole world watching and hoping, I have only sympathy for the trialists and sponsors and of course the participants. I'm seeing calls for "opening the books" and breaking blinds and increasing
transparency. I'm seeing people call for statistical tests to let us know the truth. But here's the thing: you can't make meaningful statistical claims about two events that may not even be the same. These serious adverse events are almost never so simple to figure out. Just as
Read 8 tweets
11 Sep
A friend asked me about school this fall--someone told her it would be perfectly safe because hospitals were safe. We are cautious because we have a high-risk family member. These were my thoughts. Glad to hear where I've missed something.

we're doing online only.
the evidence suggests that universal masking makes hospitals mostly pretty safe. The rates of mask compliance are >90% at hospitals, people don't hang out in crowded environments, and very few people engage in communal eating.
The spread within hospitals, which is rare) happens when people take their masks off and/or eat together.
It would take high masking compliance, actual physical distancing of kids, and no communal eating to make schools simulate a hospital environment.
Read 5 tweets
31 Aug
This CDC thing about a small minority of the COVID deaths being among previously healthy individuals? A few thoughts.
First, we already knew that SARS-CoV-2 is ruthlessly Darwinian in its assault on human beings. Our responsibility in the battle with COVID is overwhelmingly to protect people who are vulnerable.
Second, this is true of almost every fatal disease. Cancer, heart disease, strokes, certain forms of trauma. Some violent deaths (e.g., suicide, homicide) disproportionately affect the young and healthy, but almost everything else affects people who have other health problems.
Read 7 tweets
28 Aug
As we think about convalescent plasma (CP), I thought it was worth looking at the actual data in other diseases. As best I can tell, the only actual trial showing efficacy for CP is in Argentine hemorrhagic fever, published in Lancet in 1979. It's an elegant study from 1974–1978
They blinded (using FFP as the control) and enrolled based on high clinical suspicion. Among the 217 enrolled, 188 had confirmed AHF. The money shot is this one: (p=0.0002 by Fisher's exact). Image
Read 6 tweets

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