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Explore This IssueDecember 2021
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On Sept. 11, 2001, I was at work.
I had accepted a position as an assistant chief of service (ACS) for the Department of Medicine, which is Hopkins-speak for a hybrid position that involves all the administrative duties of a chief resident, plus the responsibility of an attending. For a year, I admitted patients to my service, seven days a week, with the assistance of two senior residents, four interns and a smattering of medical students.
At the time, there was a standard routine: Rounds started promptly at 8 a.m. The intern who was on call overnight presented the patients who were admitted over the past 24 hours. Patients were discussed at the bedside, so they could chime in or answer follow-up questions that were not self-evident at 3 a.m.
An oddity of the hospital at the time was that patients had to pay for services that would now be taken for granted. Phone service, for example, was not automatic; patients had to pay to purchase a disposable phone, which they could take home with them at the end of the hospitalization, if they so chose. If you wanted access to the good television stations, you had to pay a premium; if not, you were relegated to the hospital equivalent of basic cable.
Because most patients on my service had more pressing concerns than access to Sports Center and because the time of rounds were fixed, I spent the year watching a lot of Martha Stewart Living, which just happened to be broadcast in the morning on one of the free channels. This led to an odd juxtaposition, in which I would hear about patients who were admitted for endocarditis or cellulitis as Martha quietly admonished me to cut hydrangea stems lengthwise so they could drink deeply and remain plump.
I don’t clearly remember the patient who was presented to me the morning of 9/11, but I do remember he gestured to the television and commented, “Something happened.”
On the television, in place of Martha’s admonishing countenance, I saw that a freak accident had taken place: A plane had struck one of the World Trade Center towers.
The air traffic controllers in New York are responsible for some of the most densely packed flights in the country; I was always a little surprised that a major accident in New York airspace had not taken place previously.
After the newly admitted patients were presented, I excused myself as my team continued with work rounds. Some days, I might have remained with the team, but I knew that they would move faster without me, and the resident would provide me with a précis after they had finished.
So I retreated to my office and turned to my computer to find out what had happened. And I watched, wordlessly, footage of a second plane striking the South Tower.
The Before Times
When I think about my life, I think about the events that defined it. This includes my ACS year, which I still credit both for my knowledge of internal medicine and for the wrinkles that now permanently crease my brow. It also includes the explosion of the space shuttle Challenger. I remember being stuck outside a classroom with my fellow students. The room was locked, but the television was left on. I watched the space shuttle explode through the small window in the door, thinking it was a particularly tasteless parody.
It has been humbling to realize that some of my patients value my medical advice a little less than the advice that they receive from distant relatives, Instagram influencers, sports figures & podcast hosts.
And now, in this 20th anniversary year of 9/11, I have a pandemic to mark the march of time.
Previously, I thought of my life experiences as cleaved by 9/11. For example, I remember a time before the Transportation Security Administration. I know what it was like to leap out of a cab at the airport and run directly to the gate, paper ticket in hand, just moments before the flight took off. It makes me a little wistful to know that many of you will never experience that particular rush of adrenaline.
Now, I think the pandemic will be the major defining point of my life. I miss the spontaneity of the before times. It used to be simple to stop by a bar after work or suddenly decide to stop by a restaurant to see if a table might be free. For the past year, everything has had to be planned: What are their cleaning protocols? Are the tables spaced apart? Are the waitstaff masked? Are they vaccinated?
It has been exhausting to have to continually consider these issues before leaving home, even for the most workaday tasks. At the beginning of the pandemic, I groused that I had trouble remembering to put on my mask before exiting my car. Now, I sometimes have trouble remembering I’m wearing a mask because I’ve become so accustomed to its weight against my skin. But the burden of having to subconsciously incorporate these considerations into my daily routine takes a toll. And I can’t wait for it to be over.
The Fight Against COVID-19
When discussing the pandemic, it is difficult not to slip into martial metaphors: The war against COVID-19. The battle to vaccinate patients. A fight that must not be lost.
Thinking of the pandemic as a war is the only way to grasp the number of lives lost. Officially, the pandemic has taken 5 million lives, roughly the same number of soldiers and civilians who were killed during the Korean War.1
As inconceivable as that number is, it may not be large enough. The Economist points out that the official death toll does not include all those who likely died of SARS-CoV-2 but were never tested.2 It also does not include those whose lives could have been saved if hospitals were not already overwhelmed caring for patients with COVID-19. If you think about COVID-19 in terms of excess mortality—the number of people who would still be alive if there were no pandemic—the death toll increases to 19.5 million lives, which is the same death toll attributed to World War I.3
I actually thought the end of the pandemic might look a bit like the end of World War I, with ticker tape parades and celebrations in the streets.
Now, I realize the Korean War is a more appropriate analogy. There will be no peace treaty, only an armistice. Hostilities will cease, and each side will retreat, glowering across a demilitarized zone.
I think it’s increasingly clear that COVID-19 is here to stay. I’m betting that by the time you read these words, we will be in the throes of the last surge of the pandemic. Past that point, I think the pandemic will start to recede into the background, characterized by regional mini-surges, circumscribed by human behavior and local vaccination rates.
Our inability to get more vaccines into arms is the great conundrum of this pandemic. In some ways, failure was inevitable. The global initiative to eliminate polio started in 1985. We are still hacking away at that goal. Our experience with polio demonstrates that there will always be some pockets of the world beyond reach.
In the U.S., we were never going to achieve 100% vaccination. The proportion of U.S. adults vaccinated against measles hovers at a little above 90%.4 I would presume that people dodging vaccination against measles would not be eager customers for a coronavirus vaccine.
It has been humbling to realize that some of my patients value my medical advice a little less than the advice that they receive from distant relatives, Instagram influencers, sports figures and podcast hosts. There are, of course, many reasons for vaccine hesitancy. I wonder if it represents, at least in part, a failure in STEM education.
An acronym for Science, Technology, Engineering and Mathematics, STEM represents the fields that are central to a technologically advanced society. There has been an ongoing debate over whether there is too much emphasis on STEM education. I think the pandemic has made it clear the opposite is true.
Unfortunately, the last time most people thought about science was when they heard the story of Newton discovering gravity after watching an apple fall from a tree. The hidden tragedy is that this is a particularly bad example of how science works.
If Newton’s theory of gravitation were really based on the observation of apples, he would have never stopped at watching a single apple fall from a single tree. He would have repeated that experiment to demonstrate that his first observation wasn’t a fluke. He would have then expanded the conditions to include variations in weather and season. He would have looked at Granny Smith vs. McIntosh, changing variable after variable to determine if his theory held. Then, he would have encouraged his colleagues to conduct their own apple experiments to further demonstrate reproducibility.
It’s the requirement for reproducibility that I think the lay public may not grasp. So while I’m happy that my patient’s friend’s cousin recovered from COVID-19 after having received ivermectin, I don’t necessarily think that the ivermectin had anything to do with his recovery. And multiple experiments, conducted with numerous patients, seem to say the same thing.5 Similarly, post-vaccine surveillance of legions of men would argue that the outcome of Nicki Minaj’s cousin’s friend’s testicles, while tragic, does not represent some broader message regarding the safety of coronavirus vaccination.6
The key misconception is that the results of studies should reflect one’s own personal experience with the world. If this were true, many of us would be unemployed. One patient’s experience is an anecdote, and if that patient’s experience could be applied uniformly to other patients, we would have no need for clinical trials. The scientific method requires a willingness to disbelieve what you see with your eyes and trust that numerical analysis of large populations is more likely to reflect the truth. In some ways, an acceptance of science is an act of faith, and inculcation needs to start much earlier.
The best evidence that the pandemic is winding down, in my opinion, is my observation that my commute, once again, has become painful.
At the height of the pandemic, driving felt like I was touring my fiefdom; the streets were kept empty in anticipation of my approach. No longer.
Massachusetts Institute of Technology economist Siqi Zheng has stretched the concept of experience goods to describe the unanticipated benefits of a pandemic. In economics, an experience good is a product the consumer does not know how to value until after it is consumed. For example, how much is a trip to the Maldives worth? It’s hard to say until you have experienced it for yourself.7
Professor Zheng used the concept of experience goods to describe the Chinese interest in their own green new deal. In China, the pandemic led to a substantial improvement in air quality. Once experienced, the Chinese realized how much they appreciated blue skies. This stimulated a renewed interest in environmentally friendly policies, which might not have occurred to anyone pre-pandemic.
In the U.S., I think this same phenomenon may explain The Great Resignation, which led 4.3 million Americans—3% of the entire workforce—to quit their jobs in August.8 There is no better time to re-examine your life than during a pandemic, and it seems that millions of Americans are doing just that.
For those of you who are not quite ready to quit your jobs, I wanted to share with you a strategy developed by Oliver Burkeman: strategic underachievement.9 Instead of trying to achieve more, plan on achieving less. Arrange your life so that you spend your time on what you find important, which may be your career, but may also be family, friends, hobbies or other interests. Prioritize your life accordingly and allow the rest to fall away. For those of us who were born to overachievement—and, let’s face it, if you weren’t an overachiever, you probably wouldn’t be reading this column—this is a radical approach to the conduct of your life, which may be worth consideration.
Like 9/11, the pandemic marks the beginning of a transformative epoch. This may be an appropriate time for some internal transformation, as well.
Philip Seo, MD, MHS, is an associate professor of medicine at the Johns Hopkins University School of Medicine, Baltimore. He is director of both the Johns Hopkins Vasculitis Center and the Johns Hopkins Rheumatology Fellowship Program.