A Look Back at the First Full Year
Examining 2022 at Examined.
The end of 2022 marks the first full year I’ve been writing these posts, scraping together some free time outside my family life and day job. In primary care we are in the trenches, our heads down as we grind through each day’s packed schedule. I allow myself about 5 minutes for lunch, and less than that for urination. I do this with a claustrophobic vice around my face, within a dehumanized health care system, through a relentless churn of sickened people in a murderous pandemic.
Yet I have the honor and privilege of seeing people every day, hearing their stories, and sharing in their adversities and successes. They listen to me. I was never really isolated over the past three years. I’ve had the intellectual stimulation of a challenging job, and the social connection that comes with a physician’s calling. I shouldn’t complain too much. And writing this letter has truly helped me broaden the conversation, enrich relationships while forging new ones, and stretch a capacity to reach beyond the narrow office visit.
And so here’s an end-of-the-year run down on what’s been going on. I’m including some comments that people have left, because these have been just as fun for me as writing. I thank you for your trust, your support, and for your interest in the sentences I tap into my keyboard. I hope they have helped you, too.
The first letter of the year was published on January 6th. I feel like something else momentous happened on that day. Something seditious? There were also between 1-2 million new cases of Covid being contracted per day. This was the first Omicron wave, and it was crushing the workforce in hospitals, schools, and most other industries. Unvaccinated people did quite poorly. I joined the chorus about wearing a mask, a good situational mask, and supplies of Paxlovid were just starting to become available. The James Webb Space Telescope hurtled into its orbital position 1.5 million kilometers away, and opened its eyes to a dazzling world of stars and galaxies. I felt very much like a small creature on a sick planet, humbled and amazed.
There were more Covid updates and discoveries. A vignette about taking care of an elderly fellow physician who had suffered a stroke, and his advice to slow down.
My post on the poison and pleasure of drinking alcohol was a reflection on experiences with alcohol, and the science behind why it’s good to drink less. It was one of the most read of the year, and a few patients told me it significantly changed their consumption. A memorable reader comment:
We spent a week in New York, saw some shows and, one night visited the Playboy club. I drank a lot, she did not, took a cab back to the hotel. She conked right out and I spent a very unpleasant night throwing up. Lesson learned - I have little tolerance for alcohol but like you say, it increases my dopamine and releases endorphins.
Late in the month I was interviewed by a reporter for The Philadelphia Inquirer about rapid antigen tests for Covid as they became ubiquitous and free. I think my quotes held up pretty well over time. Apparently the Inquirer’s article was picked up by other media outlets, and reached 1.5 million people. Use rapid antigen tests before get togethers, but realize they are not perfect, and may miss up to 30% of cases depending on the stage of illness and other factors.
My daughter, writing under a nom de plume, shared a story about what it was like for a young person to have appendicitis in the early days of the pandemic. This was my Take Your Daughter to Your Newsletter Day, since the pandemic ruined my take your child to work day.
There is a shocking degree of hostility being directed towards healthcare workers. There are early signs of pancreatic cancer to be aware of, and Kamila Valieva wowed us with a quadruple jump on Winter Olympic skates - before that achievement became a forum for the ethics of pushing little girls in sports, abusive coaching, and Russian use of performance enhancing drugs in children.
The beloved actor and comedian Bob Sagett died from head trauma, and I wondered whether a recent Covid infection contributed. BA.2 picked up speed, and swearing is known to be good for your health.
Putin started a war of aggression in Ukraine, and millions have suffered or died since. There is a new and improved pneumonia shot called Prevnar 20. Sleep on your left side when you can. Vaccination without other mitigation efforts does not work, and Covid is a bully. Some awesome comments:
War is heartbreaking and sickening, even from all these miles away. I want to hop on a plane and comfort the "targets" of an incomprehensible bully. Thank you, also, for being a solid, open, searching, sane source of information - one of the best antidotes to BULLYosis. There is beauty in this world yet. We must all remember to see it.
Putin definitely sucks, but not so much poutine. I absolutely love the use of “target” over “victim!”
I was honored to be a guest on a podcast hosted by an amazing VP at Independence Blue Cross (who just happens to introduce me as his primary care physician). We talked about the importance of primary care. Peter loosened me up before recording by estimating that the podcast would reach 60 million people. He has an excellent sense of humor!
Paxlovid started to become more widely available, and I wrote a deep dive about how to plan for taking this antiviral medication in the event you contract Covid. Medication interactions were thorny to memorize at first, but by now we have a good handle on the major ones. Since writing that article I’ve prescribed Paxlovid hundreds of times, and the science keeps backing us up that it’s worth taking for most people with Covid.
St. Patrick’s day found me in a kind of Irish melancholy, lamenting the ongoing pandemic, the war in Ukraine, the IPCC climate report, and Catholic guilt in general. Instead of displaying green, we flew blue and yellow at our house.
I took the measure of one full day at work by listing the diagnoses I encountered on a random Wednesday in the office. The Art of Losing is about learning to accept aging, letting go of things, and being at peace with losses both trivial and catastrophic. Some really great comments, including:
As I age I have come to feel grateful for the ongoing process of losing... or at least never quite winning. It actually makes me smile a warm internal heartfelt smile. And yes it does touch that philosophical/spiritual/eternal mystery part of me quite deeply.
The Philadelphia 76ers had a pretty good run last year, and in the playoffs they faced the Toronto Raptors - in Canada - where professional athletes were required to be vaccinated against Covid. I wrote an open letter to one of my favorite 76ers, the under-vaccinated Matisse Thybulle, trying to convince him to do the right thing for himself and his team and get that second jab already. I even quoted Kareem Abdul Jabbar (who also writes on Substack). It didn’t work.
Many people started getting their second mRNA boosters. I followed the leaders and the science, and supported doing this.
Non-alcoholic spirits and mocktails are pretty good, and much safer going down the esophagus and stomach. Antacids like omeprazole/Prilosec are overused, and physicians need to periodically reassess who should really stay on them long term, according to guidelines from the American Gastrointestinal Association.
When I was younger, I might have foolishly seen an older person, hunched over, arthritic, and thought of myself as strong by comparison. But I’ve learned to see that same person as full of might. Strength is not just a measure of capacity. It is also a measure of being.
By this time of the year, we started flying blind, as Covid testing and reporting started to crumble, and the great unmasking began. CDC guidelines shifted from protecting individuals and communities to simply making sure hospitals didn’t collapse.
Boosting our metabolism is paradoxically a hard thing to do. I came up with this equation while presenting some of the science:
body weight = (calories consumed) - (calories burned) + (a whole bunch of compensatory metabolic switches that aim to maintain whatever body weight set point we’re currently at, consistent with the evolutionary advantages of a flexible metabolism that’s geared towards preserving life, but not necessarily preserving a societal construct of beauty)
Another elementary school massacre happened. Which one? we might ask. What a desperate, telling question.
Examined presents ideas and stories your primary care doc might share - if only we had more time.
Good ventilation is instrumental for better health, and Covid just exposed this for many of us. There are instruments like CO2 monitors and cheapish air filters that can help a lot… and just cracking some windows can be a really easy part of the solution. After demonstrating how toxic my car becomes during my morning commute with the windows rolled up, a comment:
I wonder if this explains my chronic headaches. We keep everything shut most of the time, especially when it's humid outside. I'm going to invest in collecting some data. The car numbers are crazy!! The world needs to crack a window!
There is significant pollution in the water that comes from the tap. We should know more about it, and perhaps invest in better water filtration units like reverse osmosis. I have one that sits on my counter and improves my drinking water.
Anxiety generally got worse for most during these pandemic years… but for a small minority, it seemed to help burn out some anxious flames.
It was announced that the fall boosters would target Omicron BA.4 and BA.5 variants. Sounded like a great idea. Spoiler alert : it was, and still is - get your bivalent booster already!
Here is a deep dive on whether a jellyfish protein called Prevagen really works for memory loss. This post seems to be the most popular one I’ve done in the algorithmic eyes of Google, as searches for “does prevagen really work” find it pretty consistently. But I’m not worthy of this comment:
I've been wondering about Prevagen. How much do they spend on TV commercials? We clearly need more truth in advertising. However, it doesn't look like it's going to happen soon. In the meantime, I'll continue to subscribe to your column Examined and to Consumer Reports... two beacons of light and hope in the intentionally dark and deceptive world of consumerism.
There were more questions about Paxlovid in the office, and more answers came as we gained more experience prescribing this antiviral.
Knee injections, with stuff like Euflexxa, Gel-One, Hyalgan, Monovisc, Orthovisc, and Supartz, are usually not worth the time, money, and risk of infection.
Monkeypox?? Are you kidding me? Another viral scourge to learn about, plan for, contain, and fear? Fortunately for us, our world’s hobbled public health infrastructure came to the rescue and mostly bottled this thing up. The initially affected communities also stepped up big, despite the conspiracy mongering, and many rolled up their sleeves for Jynneos vaccines. Monkeypox is so July, now it’s called mpox.
The American Heart Association has a cardiovascular risk assessment tool that you can use to gauge your behaviors, and make some modifications if your risk of heart attack and stroke is outsized.
In a follow up to the Prevagen post, I discussed some ways to improve and maintain our memory and cognitive superpowers that are actually evidence-based, and mostly free. For this post I received a rarely bestowed honor, the…
Double bravo! BRAVISSIMO! Although all of the installments of this newsletter have been very helpful, this latest one about preventing dementia is probably the most comprehensive and most important article to date.
The real world evidence about boosters helping continued to flow in… just as the new bivalent boosters loomed around the corner.
The medication minoxidil has been used for quite some time as a topical treatment for hair loss, and branded most famously as Rogaine. Some dermatologists are now using the pill form off-label, taken orally, as a pretty effective remedy against balding.
Paternity leave is good for dads, moms, children, and for the companies who encourage it. The U.S. lags behind other developed countries. Overcoming a sense of penalty, embarrassment, and shame as a man taking paternity leave is truly not heroic. And a thoughtful mother commented on parental leave in general:
I went back to work full-time when my son was 5 weeks old. There was nothing offered 27 years ago, except the unspoken threat that I would lose my position at work if I was not back soon enough. My son was raised in someone else's home, who saw the first steps, the first everything. I see a permanent, life-long impact this has had on my son.
I got that bivalent booster they started dialing up in June. Outstanding. You probably should, too, if you haven’t. Then you can display the free sticker I made in this post.
The 20 top research studies for primary care from 2021 were selected from over 20,000 journal articles, based on relevance and potential to change physician recommendations for good care. Most of these were big pooled studies, and here are part 1 and part 2 and part 3. This series of posts sprawled into November actually, but my own gazpacho recipe was included, just to make all this research more palatable as the last Jersey tomatoes ran out…
And with kids going back to school, I gave a cheat sheet of answers to Covid questions… hint, the answers were all Yes. I think people sensed my fatigue on this one, and the comments of support were really helpful to me. Thank you!
I wrote a quick vignette about a friend and patient I lost. It was easily the most commented upon of the year. I’ll try to share more of these sorts of reflections, because they are really what practicing medicine should be all about.
And then across field and valley, contagion and disease, beating heart and winded breath - she had endured long enough to fulfill this small quest.
We talked about problems I could not fix. I tended to them with gloves, like a gardener believing that his tinkering might grow the garden.
The garden grows.
It was hard to watch John Fetterman struggle in the Pennsylvania senatorial debate. But for most people who have had a stroke, heart attack, car accident, cancer, neurodegenerative disease, or other serious medical illness, waiting around for a “full recovery” is not a viable part of the healing process. The most courageous of us get up and keep going with whatever we have left, and with whatever productive time we are given.
The Phillies lost in the World Series. I took the loss personally, but still enjoyed a great ride while it lasted!
Expert predictions about Covid this winter (and a few of my own thrown in there) have held up pretty well going into the holidays. Now we are talking about a triple-demic of influenza, Covid, and RSV. Commenters shared even more valuable information though:
*AVOID DISNEYWORLD (all-caps intentional). I understand their desire to please everyone, but maybe just a sign or two that acknowledges the advantages of not getting sick while on vacation?
*Thanks, as always for your concise synopsis and excellent recommendations. Although I’m fully boosted and continue to mask in stores, etc., I find it’s easy to become complacent about COVID at this point.
*Crystal Ball? Haven't you heard about the scientific approach using the Magic 8 Ball LOL. You mentioned underutilized Paxlovid... I think the mindset about rebounds and anecdotal clinical gossips are hindering this process.
We got proof that Paxlovid not only reduces severe disease, hospitalization, and death… but also reduces our risks of getting long Covid.
I asked several 80+ year olds the following question: Well, despite all these issues, here you are in your 80’s. I know there is never one reason, but if you had to answer how you made it this far… what would you say? Their answers were awesome. And my favorite comment:
If you are lucky enough to grow old, you will have paid a price to get there. The price is always different... most people feel that it’s worth it. If you didn’t have to pay, life would not be so precious.
It’s too soon to get nostalgic about my own posts from 1-2 weeks ago, and definitely too meta to write about this actual post I’m writing as I type it! But I did a deep dive on vitamin D, you can find part 1 here and part 2 here.
What great information. I remember a person at my gym ended up up in the cardiac unit while mega-dosing on Vitamin D, this illustrates that we need to be wary of nutritional fads, and all “vitamins” are not like Vitamin C which is water soluble. I have been wondering how to replace the Vitamin D that was in the calcium supplement I used to take. Here in California I guess I could take off the long sleeves and step outside during the winter when the skin cancer risk is lower.
The Neanderthal photos I included in that first vitamin D post are now staring me down on my Substack homepage… and it’s kind of freaking me out. I’m hoping The Smithsonian will send me a cease and desist letter so I will be forced to take them down already.
Two thousand twenty two.
I’m sure there were times in your life, especially during these past couple years, when you wondered whether you would make it this far. I know I struggled through some dark times, and continue to feel a disruption in the force. As we cobble together some normalcy, try to repair frayed family bonds, and continue adapting to our aging bodies, I hope we can all be compassionate with each other and ourselves. As I shared on Medpage Today’s KevinMD website, writing this little substack has recharged my life in medicine somehow. I plan to keep doing it.
Talk with you soon, and thanks for being here,