by dulac89 (2020-04-27 15:44:00)
Edited on 2020-04-28 08:51:55
Sorry, long. Quick summary up front, but if you have watched the video and want a full point by point, here you go
By now most have seen the video of the Bakersfield "ER" docs (actually urgent care docs) I have been asked by (now 100s of) people my opinion. I thought I could just give my opinion, but then it becomes "oh just different doctors disagreeing". So if I'm going to disagree, I need to go point by point and explain why
Big picture: I write all of this as someone who is on the record as saying we've overshot, and need to loosen things back up to some extent. But it's not at all for the reasons these guys cite. This is one big infomercial for their urgent cares.
BLUF (Bottom Line Up Front)
1. This is not unbiased. They are business owners that run a low margin healthcare business (urgent care) that operates on volume. They say at the end of their presentation that their patients are down over 50%. You can agree or disagree with their opinions, but don’t views this as unbiased scientific data
2. Speaking of scientific data, their statistical analysis is about the worst I’ve heard from anyone in the business and violates statistics 101. Either they simply don’t understand statistics at all or are purposely trying to pull one over. Simply, they repeatedly (in multiple states and countries) look at the percentage of positive tests among those tested. They then extrapolate that to an entire state to determine how many people have had the disease, but then calculate death rates based on the ENTIRE population of the state/country (not just the extrapolated number that have had it). You cannot extrapolate testing from a high-pretest probability patient population (those presenting symptomatically with risk factors) to the general population and draw broad conclusions (specific breakdown below)
3. I agree with the premise that quarantine should focus on just the high risk population. But to do that, you have to have large amounts of testing (both disease and antibodies). You need to know who has or has had it, who doesn’t, and then you can smartly quarantine.
4. Simply put, I believe we’ve overshot. I think we need to smartly and in a limited manner open things up. In general, I think we should prioritize getting kids back in school. But these doctors make a mockery of science and it’s embarrassing. This is an opinion piece and an infomercial to get business back to their urgent cares, and nothing more.
OK so for those that want the 50,000 foot overview, stop here. For those that have watched it, and want a point by point, here you go:
First, when you're in training, the first thing you learn to do when critically evaluating research or evidence is look at who conducted it, what they were trying to show and why, who funded it, and any conflicts of interest. These two are not practicing Emergency Physicians. They own a chain of urgent cares and right now are both losing a lot of money. That doesn't make their points invalid per se, but it certainly removes any argument that this is unbiased and objective. (For comparison, I am basically salaried, I have no financial incentive one way or the other in this pandemic)
By far the worst part of this staged interview is the statistical "analysis". It's so bad, and so full of (poorly) trying to manipulate the data that, (because their statistical analysis forms the entire foundation of the rest of the arguments) it makes their arguments invalid as anything but pure (non-scientific) opinion. They are trying to argue that the deaths are much lower than we think…well yes if you think death rates are 3-4%. But I hope most people now realize that death rates are somewhere in the 0.1-1% range, and probably around 0.3%. If you don’t…they are. But that’s still terrible when you’re dealing with a disease which no one has any immunity to.
Specifics (chronologically):
1. He says that many people with chronic health problems are choosing not to come into hospitals due to fear. This is true, although to a lesser extent now than when this was filmed as ER volumes are starting to move back to normal. But we do need to de-stigmatize this to some extent as there are some deaths that are happening due to fear of coming to the hospital for other conditions.
2. “The initial models were woefully inaccurate and predicted millions of deaths. That is not materializing”. Yes, that is because the initial models that predicted this many deaths did not use social distancing. The ones that used social distancing predicted 100,000-200,000 deaths by the end of summer. Also, the IHME model everyone is talking about shows deaths levelling off and NO NEW DEATHS after August 1st. With prevalence of disease based on antibody testing, as of a week ago, showing anywhere between 4% (California) and 14% (New York), we are closer to where we were when we started all of this, not closer to herd immunity. So the idea that deaths will level off and disappear in a couple months is ludicrous.
3. In all of his examples, he extrapolates the percentage of positives out of those tested to the entire state or country. For example, he says that in California there are 12% positives, therefore there are almost 4.7 million cases in California. Uh, no. That is 12% of those tested, which had a high pre-test probability of having the disease, at the time of this video testing was almost always in those who were symptomatic. You can’t say that 12% of everyone have it when you are not testing everyone, just symptomatic people.
4. This is where it goes from bad to worse…He then says there have been almost 1300 deaths in California, and based on 4.7 million people having it, “you only have a 0.03% chance of dying in the State of California”. But again, how he came to the 4.7 million is not only terrible, but not correlated with the prevalence studies based on antibody testing, which put it more like 3%. So if you take 3% of Californians have it, that means 1.2 million had it at the time of this video. 1300 deaths out of 1.2 million is just over 0.1%. Now we’re getting a little closer to estimated mortality rates.
5. BUT, deaths lag diagnosis by on average about 2 weeks. So you can’t count number of cases and number of deaths on the same day. You have to count number of cases today, and number of deaths for the next 2 weeks at least. So just a few days after this was posted, the deaths in California are up to over 1700. So 1700 divided by 1.2 million is just over 0.14%. We probably have one more week (at least) to capture all deaths from the people who had tested positive when this video was made, so that will likely get us a little closer to 0.2%. 0.2-0.3% are consistently the best numbers coming out about mortality.
6. He then says “96% of people in California recover with no significant sequelae”. I don’t really know what that means. It’s actually better than that. He is throwing a random number out there that doesn’t even make sense to prove a point. Not a big deal overall, I just use this to point out that this whole presentation is trying to sound like a tight scientific presentation, when in fact it's not.
7. He is correct that the more we test, we will get more positives, which will bring the death rate down. But it will bring it down from the current 4% death rate, again to probably around 0.2-0.3% (not 0.03%)
8. He then says (over and over and over) “Millions of cases, small amount of deaths” Yet again, that is based on his extrapolation that 12% of California is positive. That number is likely close to 3-4%. If you take a 0.2% and apply it to all of California’s 40 million people, that is 120,000 deaths (assuming everyone is eventually infected, and there is no vaccine or cure, which probably won’t be the case but is the number using his logic). That is not a “small amount of deaths” from one disease, in one state.
9. He then goes to New York State, where his statistics get even worse. He says 256,000 cases out of 649,000 tested means 39% of those tested are positive. He then makes the same extrapolation he did in California and says that means 7.5 million people have or have had COVID in New York State. Again, the only people tested were those who were symptomatic…huge selection bias. This is where a reporter or someone in the room starts to call him out on that, and was actually correctly identifying the flaw in his assumptions, but Dr. Erickson says “right”, confidently restates his completely faulty argument, and the reporter weirdly doesn’t follow up or continue to press him which is unfortunate.
10. In New York, actual prevalence studies done around this same time indicate likely around 14% of the population has been infected (3% in upstate, 21% in New York City). That means there were closer to 2.7 million cases, not 7.5 million.
11. This is where it jumps the shark. He then says that there are 19,000 deaths out of 19 million people in New York, so New York has a fatality rate of 0.1%. Wait…he just said that there have been 7.5 million cases in New York (which is also wrong) but how can you say there are 7.5 million cases then not 1 minute later compare use all 19 million New Yorkers to calculate the death rate, not just those that you have (inaccurately) extrapolated have the disease? So 19000 out of 2.7 million is 0.7%. 0.1% would assume all New Yorkers have had COVID and there will be no more deaths….but the reality is closer to 14% have had it, and even in his (faulty) example at most 7.5 million have had it. So even if 7.5 million have had it, deaths will triple once everyone has had it. This also contradicts how he made the calculation in California.
12. Further, in both California and New York, the total population is fixed. Deaths will continue to go up. So right now we don’t know the death rate. But as a percentage of total population, the death rate can only go up…it can’t go down anymore.
13. “Milions of cases, small amount of deaths”. Only if you butcher the statistics like he is
14. He then compares this to the flu (he actually comes back to this several times). He extrapolates the 19% positive test rate nationwide to the entire US and says that “using a typical extrapolation, 64 million people have COVID in the US” and says it’s just like the flu. Again no, that's not how you extrapolate this.
15. I’ve covered the flu before – you can’t make comparisons to the flu unless you are using the same methodology for calculating flu deaths. Flu deaths are almost all presumed/extrapolated data. Only a tiny percentage of COVID deaths are presumed (in Virginia, the number is 1%. In New York it’s closer to 10%). You can criticize how deaths are counted overall but comparing flu deaths and COVID deaths are apples and oranges right now. Until the same methodology of how flu deaths are calculated is applied to COVID, they aren’t really comparable right now. The only true comparisons are CONFIRMED flu+ deaths, which is about 10-20% of estimated flu deaths.
16. Further, final flu data is calculated after the season is over. He is comparing 2 months of COVID data when we are around the steepest slope of the curve, to entire completed season of 6 months of the flu. EVEN if you want to compare current COVID deaths to the flu, we need to wait until we have at least 6 months of COVID data.
17. He then compares the US to Spain. 22% of COVID tests performed in Spain were positive, he then says that means 10,000,000 people have COVID in Spain (same faulty extrapolation). He then says there are 21,000 deaths out of 47 million which is a 0.05% chance of dying from COVID. Same false statistical analysis as California and New York.
18. He does the same faulty analysis for Sweden, I’m not going to mention using percent of performed tests and extrapolating to the entire population anymore. But his Sweden portion is worth focusing on because of additional claims he makes
19. He compares California to Sweden. At the time of his video, there were 1750 deaths in Sweden, 1220 deaths in California. California is 4 times larger. So even though his statistical extrapolation is wrong, even using his own logic you would have to say it’s equivalent to 7000 deaths in Sweden (he minimizes the differences in population and says “California has a few more people”. Well, 400% more!)
20. Except now Sweden has 2270 deaths…which in California terms would be 9000+ deaths. So assuming no more deaths and 100% of the population has been infected, we are already at 0.025% of the population. But best estimates based on antibodies is 3-4% of the population has been infected. But again he says “So Sweden, no restrictions, only 1700 deaths. California, huge restrictions, 1200 deaths. Virtually no difference” And let’s be clear, Sweden is still on the steep upslope.
21. And next… Norway to Sweden comparison. At the time he wrote this, he said Sweden had 1700 deaths and Norway 180. He says this is statistically insignificant. No, it’s not. Not even close. Sweden has twice the population, but over 5 times the death rate of Norway. One can argue that the difference between 200 deaths in population of 5 million and 2200 deaths in a population of 10 million is CLINICALLY insignificant…that’s more a matter of opinion and perspective. But it’s not even close to statistically insignificant. It's actually massively statistically significant. He then goes on to use the number of deaths as a percentage of total population that he does in all the cases above, as if the pandemic is completely over, which again is a false number. You can’t say that “your chance of death” is based on the entire population and current number of deaths. You can only say the chance of death is from the extrapolated (or in New York’s case antibody case) number, compared to deaths.
22. He then moves onto “secondary effects”. He cites increased cases of child molestation, suicides, spousal abuse, etc. The public health departments dispute these numbers, but most importantly he owns and works at urgent cares. These cases usually don’t go to urgent cares. He states they are seeing more suicides. At urgent cares? Please
23. He then discussed immunology: most of this stuff is fine and I don’t really have a problem with it, except that he compares COVID to all the other germs which most humans have some innate and/or acquired immunity to. That can’t be done. But I do agree that there may be some slight decrease in acquired immunity to all the other pathogents out there as people who shelter in place are exposed to fewer other germs. But a couple months of this isn't going to make a lick of difference. you still have plenty of germs in your house and yard. Moreso, the big problem is parents not taking their kids to the doctor to get vaccinated.
24. I love this: he says Dr Fauci is wrong because Fauci doesn’t see patients. I thought it was funny how one of the reporters asked “so how is it that you have the numbers right, and all of the other top experts around the world have this wrong? Why are you drawing different conclusions from the same patients?” And the response is “they don’t see patients. They are ivory tower academics” When the correct analysis is that "whether you see patients or not, if you can't perform a basic statistical analysis, then you don't actually know at all what your data mean"
25. Then the one that is an “immunology” expert says “we’ve studied Coronavirus since the 70s” and “this is the first Coronovirus transmissible between humans”. No, just no…most coronaviruses are transmitted human to human. If they go to animals, usually they don’t mutate to get back to humans. But almost all coronaviruses are transmissible human to human, and simply cause the common cold. He also calls Flu and COVID DNA viruses (he then says “DNA…DEOXYRIBONUCLEIC ACID” I guess because that makes him sound more authoritative.) COVID and flu are both RNA viruses. Why that’s important is that it makes these viruses genetically unstable and prone to mutation because they can’t repair errors.
26. He talks about people who think they are not being exposed to COVID who go shop at the grocery store of home depot. I entirely agree with him here. However, he says it’s inconsistent to shut churches down while opening grocery stores. He says if you’re going to shut it down, you have to shut it all down. Hopefully that concept is not something that needs to be discussed anymore…yes if you shut it all down you minimize to the greatest extent possible spread. But that’s not practical, so you have have to be smart about what you shut down and what you don’t.
27. He states they are not wearing masks because they understand immunology and want “healthy immune systems” and we won’t get that from protecting ourselves. Yes, except that novel viruses are very different due to no innate or acquired immunity. He then compares COVID to swine flu and bird flu, both of which the majority of people in the US had some (even if small) previously acquired immunity to, and both of which were not particularly deadly. The come back to this and compare exposure to common flora the same as COVID. ++But then, he says “this is why little babies, when they come out of the womb are extremely vulnerable to infection because they don’t have immunity!” He actually contradicts himself here, because he justified treating newborns who don’t have acquired immunity very conservatively, without realizing that we’re all “newborn babies” when it comes to COVID.
28. He then goes into reporting causes of death. At which point he contradicts his earlier comparison to the flu. He says “If they have heart disease, if they had COPD, they didn’t die from the flu. They died from that condition.” Yet those deaths are still counted as “flu” deaths because flu was a contributing factor. They are also counted as COPD deaths. So again if you’re going to compare death rates to the flu, you have to use similar methodology
29. He then said ER doctors are being “pressured” to add COVID to the diagnosis. If someone dies of COPD and has COVID, he said doctors are being pressured to “add” COVID even if they don’t think. I am on several emergency medicine forums/listserves, as well as the Board of Directors of my state, and this has been repeatedly polled, and tens of thousands of ER docs are saying “no” (which is my experience too). A few isolated cases of “pressure” but that is rare.
30. I agree with most of his conclusions conceptually. Especially, as I’ve discussed before, that because we’ve overshot that hospitals are far too empty, and staff has been cut back. But I find this comment funny….”because when we open things back up this will explode…we will need our hospitals, doctors, and nurses back, we will need all hands on deck.” So he just spent 45 minutes explaining why all of this is an overreaction using completely worthless statistical analysis, then admits that when things open up it could get really bad so we need to have the hospitals fully staffed. So YES. This is correct…we have overshot and using utilization of hospital resources as the best metric, we have gone too far. But almost nothing that they said in this infomercial proves this point.
A few other points: he says that he has talked to elected officials and the head of the public health department and they agree with him. When interviewed, they adamantly denied that. Of course that is “he said/she said” so we’ll never know, and they may agree but have political pressure to deny it. But they have denied regardless.
After watching this interview, I think the guy on the right actually gets it...he has strong opinions but I think he gets the basic concepts
But after watching this, I am now convinced Dr Erickson is not manipulating data to pull one over. I think he truly does not understand basic medical statistics but doesn't realize that. Ingraham actually asks some pretty intelligent questions, and specifically his response to the CMS director's tweets shows that he doesn't understand the stats that he's putting out there.
The numbers you posted below about %asymptomatic was very interesting. As you know, I had an 11 day ICU stay but my daughter (who probably brought it home from the airport) had a cough for 3 weeks, my wife lost taste/smell for 3 days - nothing else - and another daughter and son had no symptoms. They had temp to 99.4 and only know that because we took their temperature. Thanks again.
Thank you for this!
varied opinions. I do not like when someone uses the label "Emergency Physician" and false data/statistics to push and agenda.
I did not mean to make light of your extremely well thought out response to the two Bakersfield docs with my Chinatown post.
I meant no disrespect to you and I am humbled by what you have been doing: placing your life at risk trying to save the lives of others.
You are a good man and I’m proud to say you are an ND alum.
- Michael Kovacevich
Bakersfield
I have been accused of being the bearer of bad news. Perhaps it is because I see so much misinformation out there. I repeatedly try to remind myself to post equal positive as negative. In reality, I am far more positive about all of this...but I get frustrated at the people that think we're over the hump, think it's no big deal, think that it was all overblown and that's why we should open up. Sorry if my posts seem to come off too pessimistic.
...Listening to gospel music on the colored radio station
And the preacher said, you know you always have the Lord by your side
And I was so pleased to be informed of this that I ran twenty red lights in his honor
Thank you Jesus, thank you Lord
I had an arrangement to meet a girl, and I was kind of late
And I thought by the time I got there she'd be off
She'd be off with the nearest truck driver she could find
Much to my surprise, there she was sittin' in the corner
A little bleary, worse for wear and tear
Was a girl with far away eyes
So if you're down on your luck
And you can't harmonize
Find a girl with far away eyes
And if you're downright disgusted
And life ain't worth a damn
Get a girl with far away eyes
Well the preacher kept right on saying that all I had to do was send
Ten dollars to the church of the Sacred Bleeding Heart Of Jesus
Located somewhere in Los Angeles, California
And next week they'd say my prayer on the radio
And all my dreams would come true
So I did, the next week, I got a prayer with a girl
Well, you know what kind of eyes she got, well I'll tell ya
So if you're down on your luck
I know you all sympathize
Find a girl with far away eyes
And if you're downright disgusted
And life ain't worth a dime
Get a girl with far away eyes
So if you're down on your luck
I know you all sympathize
Get a girl with far away eyes
who unleashed hell on all those defenseless people with his helicopter gunship.
It is fooling so many people.
He sounds like MOrAn. He's a sharp stick in the eye guy, it was useful to spark debate.
hiding behind a facade of scientific expertise to get his cash cow back online
I was waiting for him to signal his allegiance to a certain political movement.
I generally agree with your post. I purposely did not editorialize and as someone with a math degree and multiple higher level degrees I hope My linking to the video didn’t serve as an endorsement.
Part II was question and answer, and now they are moving into responses that clearly indicate they are expressing their opinions. I'm completely OK with that. The part that pissed me (and almost all other Emergency Physicians) off was making up statistical analyses and abusing the science to sound authoritative to prove their point.
In general I'm not as turned off by their extrapolation as others because like you I understand its flaws. That said as you pointed out others won't and it's irresponsible of them to thus mislead those folks.
In my opinion, the mistake they made is expressing their extrapolation as nothing more than a lower bound estimate for a fatality rate.
The mathematician in me looks for boundaries. I think if they couched their estimate as yet another guess at a lower bound for IFR they would have been better received by your community.
Sure there's sampling bias in what they collected. Yes it's wrong to apply those positive result percentages to large populations. There are several bad assumptions required to do so.
But if they simply had said, "hey we're going to make some guesses now. The point is to show that the upper range for expected fatalities is very likely much lower than what we assumed when we decided to lockdown. That's it - what we do with that estimate is up to policy makers. That said if you're joe q average and you are operating under the assumptions from January that it's very likely that if you go outside you're going to die this estimation is something else you should consider. There are flaws in our estimation and that's why we're not saying this is a prediction or a conclusion..."
If they left it at that I think their message could have had some positive impact reducing anxiety among the population and policy makers who are probably terrified of making a decision that ends up to people needlessly dying. Instead they went whole hog and called masking unnecessary and "open up!"
Stay safe - I'm sorry if our demands on your time are taking away from sleep and healthy habits. We all owe you 1390429038 drinks of your choosing after this.
...well-presented information. The errors you point out remind me again of one of my most valuable books:
but liars figure".
Because I'm sure there isn't a perfect answer given the lack of overall %'s available.
We hear a lot about how 50% (or so) of people are asymptomatic, and only a few get so sick that they head to the hospital.
What we never hear about is the percentage (here is where guessing may come in?) of people who get the virus, get sick---but not sick enough to get admitted, and what their symptoms and ride through the illness may look like. I think if the public knew more about this side of the thing it may demystify the illness.
Are young people getting sick (showing symptoms) in reasonable numbers, or is it only people at a certain age/morbidity that have this mid-range/mild illness?
If you can't answer, no big deal, but I thought you might have some idea.
It's more likely 25%. What was found when they did the testing with so many "asymptomatic" patients is that many of them were presymptomatic. It's been shown that you can shed virus for up to 7 days before showing symptoms. So of all the original people with positive tests that were asymptomatic, at least half went on to develop symptoms shortly thereafter.
So about 50% are sick, but not sick enough to be hospitalized. I think one friend (another ER doctor) and his family are a good example. He was very sick...fever, cough, body aches, short of breath. He does Ironman triathlons and he had to stop and rest going to the bathroom. He felt terrible for about a week. His wife also got sick and tested positive, but she had no fever just a moderate cough for 4-5 days. One kid had a bad cough for 2 weeks but otherwise felt fine, and the other kid just had a stuffy nose
Bottom line is that they are all over the board. We call and follow up with every patient we discharge. Some still feel terrible, but not bad enough to get admitted. Others are feeling better.
Who had a fever for like 5 weeks. She was tested as positive but that’s really the only symptom. Has had some issues of just feeling lethargic.
But 5 weeks of a fever is just crazy I would think. It’s now just barely a fever, but for several weeks it was consistently 100/101. Just another weird reaction to Covid I guess
The other one is the cough...it can last for weeks (like 6-8 weeks)
This virus is certainly not typical of the common cold or flu
A lot of time and energy is being spent on what the demand curve is going to look like when people start coming back.
I've seen a lot of models, and the reality is, I just don't think we know.
Sure there is a ton of pent up demand, but how many people still need that procedure? Have people been able to do rehab and rest, and not go into work which aggravates the issue?
I'm not saying everyone is magically cured, but it's proving quite difficult to figure out what the demand curve is going to look like after this. Most agree it will jump back up, but how quickly, and how far back down will it come after the spike, no one knows.
It will be interesting. Will the rural facilities be able to keep the lights on long enough and weather than demand spike? If I knew for certain, I'd be retiring very soon.
screening mammograms. So far, 90 percent of women have said, "No thanks." That is a choice that I understand.
Patients have to want to come back, too.