First, a wise person messaged me to say with a fishing expedition like this, they should adjust for multiple hypothesis testing, by doing so, some of the benefits & harms will vanish, as chance variation. Good point!
Second, Alasdair Munro nicely points out the magnitude of the mental health gain:
"Why are we focussing on the tiny 9 per 100,000 person year increased risk of clots, surely we should be more interested in the massive 1500 per 100,000 person year REDUCTION in anxiety disorder!
🚨Covid is good for your mental health!*
*sarcasm"
Ha! he is right
Third, some argue that newborn kids should still get COVID vaccination b/c they would not have yet had covid. This study of course is unable to comment on that. I am not aware of any study that would pertain to (presumably 6 month olds-- who are first eligible for COVID Wuhan-strain vax in 2023) as to whether they will benefit against the new circulating strains that arise with respect to hospitalization, death, or other clinical endpoint. I look forward to seeing that trial! If positive for clinical outcomes, absolutely! If negative, nope. Since nearly no parents are getting the vax for 6 months old (<5% in USA), and since these are select people, obs studies will again be useless, plagued with confounding.
I am not buying that claims based data and Diagnosis codes are accurate. When I order a test using Epic or an EHR it requires a CPT code before the test is scheduled. These codes accrue in the medical record. And their presence does not reflect the real diagnosis but rather the billing practice. It’s sorta upcoding. So using database codes without verifying the diagnosis is a really inaccurate way to define an outcome.
I have not pulled this MMWR yet to review it but I would bet this is a Kaiser based study. They have been cranking out crappy epi science all pandemic long.
Finally MMWRs are not peer reviewed, they undergo internal review to determine if the study comports with current CDC policy.
The near uniformity of biased MMWR reports using faulty data and analyses suggests a motive away from science. Hope that the NIH can reflect on some of these reports and retract them.
The EHR requires you to diagnose someone with the condition before you can test them for the condition? How does that work?
Or do you simply have to input symptoms that warrant a specific test. I don’t see a problem with the latter. Why get a test for something for no reason?
The test requires a diagnostic code in order for billing to work. Symptoms = diagnosis in general. If you don't properly code a test, say for Vit D levels, insurance will claim not necessary. Some codes allow the test but others don't. Often multiple codes are presented in order to get around the issue. Reliance on those codes can cause misinterpretation of data.
So they can put time and money into whatever this is, but still no interest into looking into whether 1-dose might be acceptable and safer for teen boys to satisfy vaccine requirements, like Pfizer themselves said it might be?
Every day, I mute Twitter accounts (possibly real people and also bots) that are too alarmist for my personal tolerance, and I just muted some doctor who tweeted about this study.
How will we ever trust our institutions and even our own physicians again? It is very discouraging. I’m sure many have reached a point where they are no longer comfortable trusting our basic health needs to the physicians we deal with regularly. I’m thinking it’s not good on so many levels. Makes me sad.
You highlighted the mental health paradox but not the most damning part of all. Covid patients are less likely to have respiratory post viral sequelae?! This is by far the most common "long covid" symptom. Cough frequently can linger for weeks-months. Clearly they are not comparing apples to apples.
Vinay, I am enjoying watching you be red-pilled on the horror of the government. Over the years I have come to believe that these people are not just stupid, but are actually evil in that their only purpose is to comport to the (generally left wing) narrative-du-jour rather than to any science.
I believe public health is beyond rescue in the American mind -- and I have come to believe it should be. My biggest worry, expressed here since you started writing, is the spillover to non-public health practitioners. The pediatricians are the worst and I get more calls from parents questioning the blather they keep spouting than from any other group. But no one intelligent is believing most anything that the medical community says today and, sadly, one can understand why.
There just is not bandwidth to explain everything one concludes about a patient during a visit -- four years of college, four of medical school, four of residency and two of fellowship, followed by 30 of practice, cannot be encapsulated in three minutes. But patients are losing trust in this essence of the physician-patient interaction because they have (with cause) come to believe that many doctors are just parroting the official line without understanding the facts (as so well explained in your article today) and without considering the individual patient's relationship to those facts.
We will likely not repair this during my lifetime which makes me very sad -- I have spent my entire life patient by patient, not government directive by government directive, but patients have been burned and will be a long time recovering.
Thanks for your strident take on this all. As another point (you still need a copy editor) in the final sentence "of" should be "off" -- powerful line, though.
I imagine your fears are quite real and I am unsure why so many have not been critically addressing government advice. Most doctors seem to take on the advice and not address their patients' concerns. Is it a matter of time for study and analysis, a lack of curiosity?
For the record, I enjoy your insightful comments on various stacks. Just in case you were wondering if they were read.
It is a pivotal comment, I believe. I think, even more than patients, most doctors (who overwhelmingly are interested in taking good care of their patients, despite much of the chatter on these stacks) find it even harder to believe that organizations on which they have built their trust framework (CDC, FDA [let us have a Thalidomide redux discussion now, etc.], NIH and their professional associations (especially AAP and AMA) are so untrustworthy.
Because the volume of information with which to deal is so large, one of the "legitimate cheats" for much of this is to assume that some set of organizations would only promulgate the best information. The facts are that COVID shows this is utterly untrue, and may have been untrue about who-knows-what-else for who-knows-how-long. That is a difficult bolus to swallow and erodes most of the "keep up with the advances in medical knowledge" framework that almost all docs use.
I have always been the token skeptic (it is in my personality, and I have enough publications and financial support that I am more unassailable than most in my academic home to the predations of the masses). For example, I have been railing against the AHA "low fat" guidelines since they came out (a very long time ago) and, of course, they have recently been shown to be the source of most of the fat people there now are. The list is long. But saying "low fat should make you less fat" and being credible as an organization makes it hard for most docs to do anything but nod and add that to their advice pile.
I am spending lots of time with the current crop of medical students (at least the smart ones) trying to teach them that what they think they know they may not and what they are being told may have other than pure motivations. It is a slow process against the current, but one has to hope that it eventually helps to correct the nonsense we see now.
Thanks. The story "difficult bolus to swallow and erodes most of the "keep up with the advances in medical knowledge" framework that almost all docs use." I assume few practitioners have the time to track the extraordinary explosion (and evolution) of pandemic debate.
I signed up for your Substack after looking at some of your Youtube covid videos, particularly the Annals vs MMWR studies on long COVID. I'm hoping you continue to follow and make updates on long COVID in adults. I have friends who are scared to death of long COVID based on following Twitter threads about the huge incidence, and T-cell exhaustion, and, and....
The main thing I took away from my training in biostatistics and study design is that humans don't intuitively grasp the category difference between observed correlations vs prospectively gathered controlled data. They have to learn this. Congrats on being the full professor who can now focus his abundant energy on this task!
This bears repeating- “ But worst of all is just how bad many doctors are at doing science, reading science, and making scientific arguments.” I left my PCP after 22 years because he told me that masks work. His evidence? Since the practice instituted mask mandates, they didn’t have any flu. He was so convinced, he wanted to make masking permanent. Never mind that they also instituted a policy of not allowing anyone with any cold symptom at all inside the building. (Those patients are seen outside, in the parking lot.) Never mind that there was no flu anywhere. My PCP is very intelligent, graduated from elite schools, but a child could do better science than this!
Started dating someone recently. I really like her. It was a huge relief to find out she's very alt-middle: believes vaccines should be for the vulnerable, didn't vaccine her young and healthy children, and only wears a mask when it's required.
You wouldn't believe how many dating app profiles (here in the Los Angeles area) have "vaccinated" or "triple vaxxed" or "swipe left if you're unvaccinated."
Three updates to this piece:
First, a wise person messaged me to say with a fishing expedition like this, they should adjust for multiple hypothesis testing, by doing so, some of the benefits & harms will vanish, as chance variation. Good point!
Second, Alasdair Munro nicely points out the magnitude of the mental health gain:
"Why are we focussing on the tiny 9 per 100,000 person year increased risk of clots, surely we should be more interested in the massive 1500 per 100,000 person year REDUCTION in anxiety disorder!
🚨Covid is good for your mental health!*
*sarcasm"
Ha! he is right
Third, some argue that newborn kids should still get COVID vaccination b/c they would not have yet had covid. This study of course is unable to comment on that. I am not aware of any study that would pertain to (presumably 6 month olds-- who are first eligible for COVID Wuhan-strain vax in 2023) as to whether they will benefit against the new circulating strains that arise with respect to hospitalization, death, or other clinical endpoint. I look forward to seeing that trial! If positive for clinical outcomes, absolutely! If negative, nope. Since nearly no parents are getting the vax for 6 months old (<5% in USA), and since these are select people, obs studies will again be useless, plagued with confounding.
At *SOME* point, this clown show has to stop, right? RIGHT? Dear GOD, please say yes!
I am not buying that claims based data and Diagnosis codes are accurate. When I order a test using Epic or an EHR it requires a CPT code before the test is scheduled. These codes accrue in the medical record. And their presence does not reflect the real diagnosis but rather the billing practice. It’s sorta upcoding. So using database codes without verifying the diagnosis is a really inaccurate way to define an outcome.
I have not pulled this MMWR yet to review it but I would bet this is a Kaiser based study. They have been cranking out crappy epi science all pandemic long.
Finally MMWRs are not peer reviewed, they undergo internal review to determine if the study comports with current CDC policy.
The near uniformity of biased MMWR reports using faulty data and analyses suggests a motive away from science. Hope that the NIH can reflect on some of these reports and retract them.
The EHR requires you to diagnose someone with the condition before you can test them for the condition? How does that work?
Or do you simply have to input symptoms that warrant a specific test. I don’t see a problem with the latter. Why get a test for something for no reason?
The test requires a diagnostic code in order for billing to work. Symptoms = diagnosis in general. If you don't properly code a test, say for Vit D levels, insurance will claim not necessary. Some codes allow the test but others don't. Often multiple codes are presented in order to get around the issue. Reliance on those codes can cause misinterpretation of data.
You are one of the few doctors I trust. Thank you for providing perspective in these matters!
So they can put time and money into whatever this is, but still no interest into looking into whether 1-dose might be acceptable and safer for teen boys to satisfy vaccine requirements, like Pfizer themselves said it might be?
Every day, I mute Twitter accounts (possibly real people and also bots) that are too alarmist for my personal tolerance, and I just muted some doctor who tweeted about this study.
How will we ever trust our institutions and even our own physicians again? It is very discouraging. I’m sure many have reached a point where they are no longer comfortable trusting our basic health needs to the physicians we deal with regularly. I’m thinking it’s not good on so many levels. Makes me sad.
You highlighted the mental health paradox but not the most damning part of all. Covid patients are less likely to have respiratory post viral sequelae?! This is by far the most common "long covid" symptom. Cough frequently can linger for weeks-months. Clearly they are not comparing apples to apples.
Vinay, I am enjoying watching you be red-pilled on the horror of the government. Over the years I have come to believe that these people are not just stupid, but are actually evil in that their only purpose is to comport to the (generally left wing) narrative-du-jour rather than to any science.
I believe public health is beyond rescue in the American mind -- and I have come to believe it should be. My biggest worry, expressed here since you started writing, is the spillover to non-public health practitioners. The pediatricians are the worst and I get more calls from parents questioning the blather they keep spouting than from any other group. But no one intelligent is believing most anything that the medical community says today and, sadly, one can understand why.
There just is not bandwidth to explain everything one concludes about a patient during a visit -- four years of college, four of medical school, four of residency and two of fellowship, followed by 30 of practice, cannot be encapsulated in three minutes. But patients are losing trust in this essence of the physician-patient interaction because they have (with cause) come to believe that many doctors are just parroting the official line without understanding the facts (as so well explained in your article today) and without considering the individual patient's relationship to those facts.
We will likely not repair this during my lifetime which makes me very sad -- I have spent my entire life patient by patient, not government directive by government directive, but patients have been burned and will be a long time recovering.
Thanks for your strident take on this all. As another point (you still need a copy editor) in the final sentence "of" should be "off" -- powerful line, though.
I imagine your fears are quite real and I am unsure why so many have not been critically addressing government advice. Most doctors seem to take on the advice and not address their patients' concerns. Is it a matter of time for study and analysis, a lack of curiosity?
For the record, I enjoy your insightful comments on various stacks. Just in case you were wondering if they were read.
It is a pivotal comment, I believe. I think, even more than patients, most doctors (who overwhelmingly are interested in taking good care of their patients, despite much of the chatter on these stacks) find it even harder to believe that organizations on which they have built their trust framework (CDC, FDA [let us have a Thalidomide redux discussion now, etc.], NIH and their professional associations (especially AAP and AMA) are so untrustworthy.
Because the volume of information with which to deal is so large, one of the "legitimate cheats" for much of this is to assume that some set of organizations would only promulgate the best information. The facts are that COVID shows this is utterly untrue, and may have been untrue about who-knows-what-else for who-knows-how-long. That is a difficult bolus to swallow and erodes most of the "keep up with the advances in medical knowledge" framework that almost all docs use.
I have always been the token skeptic (it is in my personality, and I have enough publications and financial support that I am more unassailable than most in my academic home to the predations of the masses). For example, I have been railing against the AHA "low fat" guidelines since they came out (a very long time ago) and, of course, they have recently been shown to be the source of most of the fat people there now are. The list is long. But saying "low fat should make you less fat" and being credible as an organization makes it hard for most docs to do anything but nod and add that to their advice pile.
I am spending lots of time with the current crop of medical students (at least the smart ones) trying to teach them that what they think they know they may not and what they are being told may have other than pure motivations. It is a slow process against the current, but one has to hope that it eventually helps to correct the nonsense we see now.
Great question...thanks for making me think.
Thanks. The story "difficult bolus to swallow and erodes most of the "keep up with the advances in medical knowledge" framework that almost all docs use." I assume few practitioners have the time to track the extraordinary explosion (and evolution) of pandemic debate.
I admire your prodigous energy!
I signed up for your Substack after looking at some of your Youtube covid videos, particularly the Annals vs MMWR studies on long COVID. I'm hoping you continue to follow and make updates on long COVID in adults. I have friends who are scared to death of long COVID based on following Twitter threads about the huge incidence, and T-cell exhaustion, and, and....
The main thing I took away from my training in biostatistics and study design is that humans don't intuitively grasp the category difference between observed correlations vs prospectively gathered controlled data. They have to learn this. Congrats on being the full professor who can now focus his abundant energy on this task!
This bears repeating- “ But worst of all is just how bad many doctors are at doing science, reading science, and making scientific arguments.” I left my PCP after 22 years because he told me that masks work. His evidence? Since the practice instituted mask mandates, they didn’t have any flu. He was so convinced, he wanted to make masking permanent. Never mind that they also instituted a policy of not allowing anyone with any cold symptom at all inside the building. (Those patients are seen outside, in the parking lot.) Never mind that there was no flu anywhere. My PCP is very intelligent, graduated from elite schools, but a child could do better science than this!
Started dating someone recently. I really like her. It was a huge relief to find out she's very alt-middle: believes vaccines should be for the vulnerable, didn't vaccine her young and healthy children, and only wears a mask when it's required.
You wouldn't believe how many dating app profiles (here in the Los Angeles area) have "vaccinated" or "triple vaxxed" or "swipe left if you're unvaccinated."