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A Year of Extremes: From Medieval Masks to mRNA Vaccines; From Science Denying Flat Earthers to the Prospect of Civil War

What a year this has been. Our lives continue to be upended, and in many cases cut short, by this novel virus. And our responses include everything from the most sophisticated new medical technologies to medieval strategies. In fact, French Royal physician DeLorme invented PPE in 1619, all the way from clothing that covered the entire body without gaps to the birdlike face mask that filtered the air that plague doctors were breathing. It is almost mind boggling that over 400 years later, we are doing the exact same thing.

But at the same time, the introduction of the Covid mRNA vaccines is equally remarkable. The first gene sequencing, of the RNA virus called Bacteriophage MS2, happened in 1976, when I was in my second year of medical school. And it took from 1990 to 2003 to complete the sequencing of the human genome.

In this strange era of coexisting medieval and space age technologies, I cannot help thinking about the tension between those who embrace both of these strategies and those who deny both. You would think the tension would be between the new and the old ways, but that isn’t as great as the one between all and nothing.

It is as if we have, in this and many western countries, two incompatible world views, like the flat earthers and the rest of us. But in this case, the size of each camp seems to be frighteningly close to equal. And the fervor that is evident in those who want to do nothing to protect themselves from the virus is truly unsettling.

I imagined that mask wearing would be an inoffensive practice, which at least wouldn’t bother anybody else. But no, people get assaulted and harassed for doing it, for making a personal choice to protect themselves.

Many experts are predicting that the pandemic will become endemic and that continued booster shots will contain its lethality. But there are no signs that the tension between the do-somethings and the do-nothings will go away.

Instead of drawing together to fight the invader, the red and blue White American subpopulations have started to view each other as the adversary. I don’t think the insurrection of 1/6/21 would have happened if we hadn’t been in the middle of this pandemic. We are like dogs who suddenly turn on each other instead of attacking the intruder at our gate.

One of these dogs appears to be more aggressive than the other, perhaps even rabid. Or is it just that much more frightened? Not frightened by the virus, but by the Black Lives Matter, Mee-Too and Environmentalist movements they see as threats to their “Freedom”, which they believe they will lose if others gain theirs.

It seems this virus was a catalyst for a chemical, cultural chain reaction whose end product is as of yet unknown. We are witnessing incompatible progress and regression rapidly reshaping and destabilizing this country.

God bless America. God help America.

I Hate to Encourage Pharmacy Shopping, But I Have to

In a perfect world, patients have one primary care doctor who knows what their specialist doctors are doing, prescribing and recommending, and one pharmacy that watches out for interactions between their treating physicians’ prescriptions.

But sometimes I just have to tell my patients to shop around for their medications, even though that creates some risks.

I have many patients without prescription insurance. Some of them are on our sliding fee program and also qualify for free drugs from the pharmaceutical companies. We call that prescription assistance. A coordinator within my organization helps patients apply for this and they may get several different brand name drugs from different companies. It is obviously up to me to make sure there are no interactions between the drugs I prescribe. But if such a patient fills a new medication at the pharmacy from an emergency room or specialist doctor, there is no one watching over this, because no one has that kind of information.

The other day I saw a new patient who had quit his job and moved to Maine. Six months from now he will have Medicare, but right now he is without insurance. He is a diabetic and takes half a dozen medications. He uses Walmart, which made sense to him as he was moving from one state to another and was able to transfer his prescriptions. But one of his latest prescriptions was an expensive diabetes medication. Alogliptin was one I had never heard of, but because sister drugs usually end with the same syllable, I deducted that it was a generic in the same family as Januvia.

This drug costs over $300 per month at Walmart. The discount website GoodRx has coupons for different pharmacies. The Walmart coupon brings the cost down to $160.63, but there is a better deal at $94.57 with Walgreens.

So I refilled his metformin and glipizide at Walmart and sent the alogliptin to Walgreens. The next day I got a call from the Walgreens pharmacist, asking why I had a diabetic on such a fancy drug as monotherapy instead of something more basic like metformin or glipizide. I told him the patient was on both, but at Walmart.

Continuity of care isn’t just a provider issue. It is also a pharmacy issue. We sometimes forget that. But it can come with a cost to the patients because of wide variation in drug prices. And this isn’t just for people without insurance. Medicare patients regularly end up in the benefit gap we call the doughnut hole, when their Medicare D prescription benefit is exhausted partway through the year. Those people, too, will find the best deal they can with competing pharmacies.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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