A friend sent this video my way along with some questions from a family member. The questions were of a specific and limited scope, which I deeply appreciate, and I hope I will have answered them satisfactorily within this post. The video is of Dr. Ivette Lozano, MD, who is general surgery trained and now runs a solo general medicine practice in Dallas, an hour and a half North of where I work; I am not sure whether she also works in surgical and/or hospital settings, as this information is not available from her website and does not come up in the video. She was speaking at the Set Texas Free Rally in Dallas on May 9th. Dr. Lozano has done numerous interviews and television appearances during the COVID-19 crisis and has these collected on her practice website; though I will keep commentary focused mainly on the video that was sent to me, watching her other interviews has been helpful in understanding her experiences and position more clearly, and I will refer to those at certain points as well. I do not feel that it would be appropriate for me to link to her practice website directly from a blog post that seeks to discredit and contradict so many of her claims, but if you wish to see her other interviews they seem to be available on YouTube.
I’d like to point out two things about this video right from the start. First, unlike the personal youtube videos we have looked at so far and and the extensively produced PlanDemic documentary, Dr. Lozano is speaking in a live, outdoor forum without the option of editing or multiple takes. She speaks for 13 minutes and seems to consult her notes very infrequently, if at all. That in itself is an impressive feat. I’ve spoken at this type of gathering a few times as a professional, sometimes on very little notice, and I honestly can’t remember half the stuff I said afterwards; it’s just not the most conducive to an academic discussion. With that in mind, if Dr. Lozano does ere in some finer details or specifics, I think a measure of grace is called for; in such a setting, it would be at least as likely that such an error were due to the challenges of that context and not to design.
The second is that Dr. Lozano states multiple times (and we will examine these instances more closely as we come to them) that she is speaking from her own personal experiences. In common experience this tends to serve as a rebuff to any attempts at correction or argument. I do not mean that this is Dr. Lozano’s intent; I only mean that we need to point this out now to preempt any blanket objection to a thorough evaluation of her claims with such phrases as, “well she is sharing her own experiences, so you can’t argue against that with statistics or outside information. She is just telling her story.” In scientific pursuits, and in her role as a physician, her statement that she is relying only on her own experiences should properly be understood as her ceding that her evidence, while compelling to her personally, is in fact anecdotal; that is, based on a small sample size that has not been studied rigorously and is not likely to represent an entire population. Dr. Lozano, as a clinician and scientist, would no doubt understand this.
Anecdotal evidence is important in medicine. It serves as a jumping off point for examining trends and leading to more rigorous research, and as an anchor for contextualizing results and treatment guidelines. In absence of anything better, we rely on our own limited experiences in treating patients; but the principles of evidence based medicine also dictate that, as scientists, we rely on stronger forms of evidence when they are available. If that evidence seems to contradict what we ourselves have experienced, that is reason to both examine the evidence more carefully, and to reflect on our own clinical experiences with a greater degree of scrutiny and honesty. Most often there are factors at play that our limited experiences and volume of data simply cannot reveal, and once we account for these our own experiences really do harmonize with the evidence after all. In fact, it’s fair to say that, to a large degree, what we call high quality evidence is really just the experiences of many, many physicians and patients aggregated and then evaluated rigorously; we ignore the experiences of many in favor of our own individual narratives only at great peril to ourselves and our patients.
So, as we look at these claims, please do not fall into the trap of thinking that as personal experience her claims are exempt from contestation. That is a legitimate and important way to interact with individuals in a great many contexts, and listening to people’s stories without judgement is a vital part of what I do every day as a physician; but it is not the way either Dr. Lozano or myself have been trained to think of medical data.
00:18 “I am currently treating COVID patients in my office.”
I am, too. It is important when we talk about our own anecdotal experiences that we at least give some idea of volume. I have interacted with only a few COVID-19 + patients; our county and city has had a blissfully small burden of disease from this virus and has not yet hit anything like a surge. Dallas, a much larger metropolitan area, has been hit harder, and I would readily believe that Dr. Lozano has seen more COVID-19 patients than I have personally; though she does not here give an indication of the number of cases she has personally treated. Yet, Texas also has had relatively few cases, and so both of our experiences would pale in comparison to those of clinicians in New York, Wuhan China, Italy, Spain, etc. We need to have the humility, as doctors, to recognize that our own small samples cannot lead to definitive clinical data on their own.
00:25 – 1:23 “Let’s start with some simple numbers.”
- 330 million in the US
- 29 million in the State of Texas
- 2 million people in Dallas
- Dallas: 111
Dr. Lozano: “When you see those numbers it kind of shocks you, that we could stop society for one hundred and eleven deaths.”Dr. Lozano
So here is my first objection. The Number of deaths in Dallas County, 111 (now 145), has nothing to do with two things. First, it has nothing to do with the populations of either the entire United States or of the State of Texas. If you want to include those numbers, your data set would look something like this:
- Population 330 million
- 89,932 Deaths from COVID-19
- Population 29 million
- 1,336 Deaths from COVID-19
- Population 2 million
- 111 Deaths from COVID-19
If you are not going to include the number of deaths (underestimated though they may be) in the US and Texas, why include those populations? I believe it’s simply to make the 111 deaths in Dallas seem small in comparison. I could do this in Waco, too; I could stand up at a rally and say “the population of the US is 330 million, and there are 257 thousand people in McLennan Country. We’ve only had 4 deaths. Are we really going to shut down all of society for 4 deaths?” It sounds pretty silly doesn’t it, to invoke that 330 million people without mentioning the 90 thousand lives lost among them?
Now, maybe it sounds like I am splitting hairs, but this is important; the reason that we shouldn’t invoke population numbers detached from death numbers is because the 111 deaths in Dallas also has nothing to do with shutting down Dallas. Think about that for a moment. Cities, States, and Nations that were not hit early by the pandemic have had the privilege of developing their response based on the impact in other places. Shutting down Dallas wasn’t based on 111 people in Dallas losing their lives to COVID-19; it was based on over 15,000 deaths in New York, 27,000 deaths in England, and 32,000 deaths in Italy. It was based on the recognition of what this virus can do to a city or a region, particularly once the healthcare infrastructure is overwhelmed. In fact, in saying that Dallas was shutdown because of only 111 deaths, she is exactly reversing the logical relationship between those ideas; the reality is that there have likely only been 111 deaths because Dallas was shutdown.
Dr. Lozano goes on, “here is how it is notified to you:”
- 27,000 Positive Covid Tests (??? but probably Texas)
- 3,000 Recovered (???)
- 111 Dead (Dallas)
- “If 3,000 have recovered, from 127,000 (???) positive tests, that’s 124,000 that have recovered.”
Now it’s clear that Dr. Lozano misspeaks here, either with the 27,000 or the 127,000 above; please remember, she is speaking in a very challenging format and such things happen. However, I honestly cannot tell which is the statistic she intended. Looking back at data from May 9th, Texas had around 37,000 positive COVID-19 cases and 1049 deaths, but listed 19,000 as recovered, not 3,000. Dallas had 111 deaths but to date has only had about 6,000 confirmed cases total, and the US was already in the millions of cases by that time. So, without knowing where her numbers have come from, it’s a bit hard for me to fully examined the claims she is making, but we can safely make at least three observations.
First, she is now directly comparing the number of cases in Texas (the 27,000 above; I cannot imagine where else this number could have come from) to the number of deaths in Dallas only, without mentioning the number of cases in Dallas at all. This is deceitful use of statistics and I sincerely hope it was accidental. Second, her point seems to be that the public is being lied to about the number of cases that are recovered; “27,000 cases, only 3,000 recovered.” But this is not the case; at the time of her speech, official data placed those numbers at 37,000 cases and 19,000 recovered. Third, her final conclusion (here she misspeaks again but her intent is clear) that the number of cases minus the number of deaths equals the number of recoveries is erroneous both because we do not yet know the long term ramifications of the disease, and more to the point, because there are still over a million people with the illness in the US who have not yet recovered. Most of them are at home under close observation and follow-up, but many are fighting for their lives in the ICU and are by no means ‘out of the woods’; some of these people are in the ICU in Texas, and we cannot discount their struggle and the suffering and danger they are still facing. Some will still die, despite the best efforts of their doctors and nurses.
1:23 “I don’t want to bring statistics from other physicians because there is always someone on the Left who wants to contradict me.”
This is the portion of the video where Dr. Lozano begins to speak about her personal experiences, but I want to spend one more moment on this very troubling statement. The politicization of COVID-19 within the medical field is largely a false narrative, and not a particularly coherent one. We’ve talked about this a lot on this blog, on multiple occasions, but basically the conspiracy theorists would like you take any doctors you happen to know and trust, or who share their conspiracy theory, and put them in the “one of the good ones” box; the few honest doctors fighting for the truth. All the rest of us, even if we happen to share your background or faith or even political leanings, are to be put in the “part of the system” box and seen as either infamous conspirators or unwitting patsies. We are, so they argue, inflating death numbers, scamming medicare, and lying to the public in order to… do… something. This part isn’t really clear, you see. Despite the vast scope of different political allegiances, backgrounds, economic views, and personal convictions among doctors, we are all somehow part of a conspiracy to destroy the economy, embarrass Donald Trump, bring about a totalitarian police state, enact socialism, etc. Despite many docs I know getting all of their news from Fox, despite some being close to retirement and watching their 401k’s like hawks, despite many having voted for Trump and planning to again, despite the fact that we are not a monolith. Despite the fact that we have had to work extra hard to take care of our patients in the midst of a pandemic, and the fact that many of us have gotten sick, and some have died, doing so. Despite the fact that, a few minutes later, most conspiracy theorists will point to empty ER’s and closing doctor’s offices in non-surge areas as a sign of the economic injury being done by mitigation measures, their conspiracy theories still call for those doctors struggling the most financially to be a part of a conspiracy to propagate the COVID-19 myth. It’s all rather silly, I’m afraid.
Which is why it is so alarming to see Dr. Lozano adopting it here. What she is saying is that she is only willing to rely on her own anecdotal evidence in talking about and treating COVID-19 because she believes that the experiences of her colleagues and higher quality data from research hospitals around the globe are skewed by a Leftist political agenda. This is a very, very dangerous way to practice medicine. At best, Dr. Lozano knows her audience and is willing to let them believe in these conspiracy theories in spite of her knowledge of the way medicine actually works, and the devotion that the overwhelming majority of doctors have to both veracity and the health of their patients regardless of their own political leanings. At worst, she has come to believe in this perverse and pessimistic view of physicians herself. My fear is that this perspective ultimately leads to practicing ‘lone wolf’ medicine detached from evidence, the insights and experiences of peers, and the commiseration and accountability that come from serving within this ancient and altruistic profession.
But because this Southern, Homeschooled, Eagle Scout, 4-wheeler-riding (is that still a conservative credential?) future-missionary-doctor has seen the compassion, the integrity, and the seemingly endless self-sacrifice of fellow physicians from every walk of life and all parts of political spectrum time and time again, I cannot be so quick to attribute to them nefarious political motivations capable of overwhelming their commitment to their calling and Oath. So when discussing Dr. Lozano’s anecdotal evidence, I will be relying on something more substantial than just my own.
1:48-2:05 Discussion of Symptoms
Here Dr. Lozano is discussing the patients with COVID-19 she has seen in clinic. I only point this out to note two things moving forward; first, she does not give us the number of patients she has actually seen in clinic who have the diagnosis. Second, her description of symptoms is interesting. She describes fever, but only fever at nighttime. She describes cough, but only with deep breaths. These are very specific qualifiers and do not exactly match what is known from observations of millions of cases of COVID-19 around the world. Many patients have cough, but not necessary only with deep breathing. Many patients have fever, but not necessarily only at nighttime. To me this suggests that Dr. Lozano may have seen a relatively small number of COVID-19 patients, because there does not seem to be much variability in the presentations she has encountered. It also illustrates the danger of relying on anecdotal evidence alone; once we have cemented a narrative that says this disease will always act like I have personally seen it act before, we put ourselves at risk of delaying the proper diagnosis or missing it entirely. We must learn from each other.
2:06 “These patients are afraid.”
This is true. One of the most important tasks we’ve had as physicians, and really as an entire healthcare field, has been to speak to the fears of our patients in the face of this very dangerous pandemic and help them navigate their medical and mental health needs with safety and confidence. This is an important part of our conversations with patients on every level, from individual encounters to entire populations. Every patient I see who has been exposed to the virus or who has symptoms that might be consistent with COVID-19 needs both reassurance and anticipatory guidance; they need to know what happens next, how to stay safe and keep their loved ones safe, and when they need to seek additional care. Our clinic system has instituted countless measures both to support our COVID-19 patients and to ensure that our patients know they can be safely seen for their chronic conditions as well, from telemedicine systems being built in a matter of weeks to patients being seen in their vehicles so they don’t have to enter into healthcare spaces, and a thousand small steps that probably go unnoticed but reduce our patients’ potential of being exposed to the virus. As physicians, we must combat fear with our compassion and the trust we have built with our patients; never with minimizing their concerns or spreading misinformation.
But Dr. Lozano then goes a step further. At 2:25 she states that the patients who are coming to see her for COVID-19 symptoms are being turned away from the emergency room. She says they are being sent home if they have a fever and told to quarantine, and that during that time they infect their families. She says that doctors are closing their doors and implementing telemedicine, which she considers a scandal because it does not involve a physical exam. She says near the end of the video that they are having patients ‘see their assistants’ instead, implying that they are having Nurse Practitioners and Physician Assistants take on risks they aren’t willing to themselves (and playing to the undeserved discrimination those professionals face in healthcare).
At 3:17, she says that other doctors are hiding in their fancy homes with their fancy cars in the midst of a pandemic, and the contempt for others in her profession is evident in each syllable she pronounces.
Her implication is that doctors are scared of the virus and are too timid to treat their patients; they are refusing to see people, the ER is turning people away, and they are using telemedicine and other tricks to avoid having to give compassionate care that might put themselves in danger from the virus. And if that’s true, it’s a tragedy; it represents the deepest betrayal of our Oaths and the values we hold in common as physicians.
But thankfully, it’s not true. When I heard her say this I really had to grieve for a moment; grieve for a doctor whose experiences and views have so detached her from the rest of her profession that she could hold, and promote, a view of physicians that is such a stark contrast to the reality. Please take a moment and really, honestly compare her narrative to the stories you are hearing and seeing from doctors all over the world; the doctors who are staying in donated hotel rooms or sleeping in the hospital call room between shifts because they are too frightened of the virus infecting their own families. Notice that they aren’t cancelling or no-showing their shifts; they are still taking care of patients every day, placing themselves in harms way and risking their live for others as they have been called to do, but they are also taking on the sacrifice of isolation themselves in order to protect those they love. Consider the doctors, even very old doctors who have come out of retirement to help and young doctors still in residency, who have gotten sick and died in the line of duty. Her narrative, at least on the physician side, doesn’t match the reality. And as much as I love my fancy car (it’s a motorcycle with a sidecar I bought used my first year out of residency; I’ve wanted one ever since I watched Indiana Jones and the Last Crusade as a kid and I’m immensely proud of it), her actively promoting for her audience the myth that most physicians lead lives of extravagant wealth (sidecar motorcycles not withstanding) is not only disingenuous but extremely mean spirited. Many of us are currently drowning in medical school debt.
But what about the patient side? Are patients really being turned away? Well first of all, it’s not only bad business and bad medicine but actually illegal to be denied treatment for an emergent condition at an emergency room. Moreover, in practice I’ve never even seen it done even for non-life-threatening conditions, and in fact one of the biggest problems with our healthcare system is that this means a great many people get all of their care from the ER because they don’t have access to a primary care doctor (when my residency program was founded 50 years ago, this was one of the problems it was created to address). Again, Dr. Lozano’s narrative seems to be the exact opposite of the real situation. From her comments alone you would think that patients with cough and fever were having the doors barred from entering their clinic or the ER; but in many areas that have been working under the assumption that a COVID-19 surge was imminent, most clinics and hospitals have deferred a great deal of other types of care in order to specifically care for large numbers of people with those exact symptoms. We have worked very hard to ensure that our other patients are still getting close follow-up, and things like telemedicine have been put into place to make sure that my 95 year old patient with COPD and congestive heart failure can still get seen without being exposed to the transmission risks inherent in a clinic waiting room. No, patients with cough and fever are not finding a series of doors slammed in their faces, with Dr. Lozano being their last hope; but that isn’t what she’s actually saying.
4:05 Treatment for COVID-19
I promise we’ll get somewhat political momentarily, at least in the sense of giving governing officials their due while not ascribing to them godlike mastery of all intellectual disciplines, and of honestly reflecting on the merits and limitations of national and state medical associations. But let’s press on for now.
When Dr. Lozano was speaking of the patients being sent home and turned away, it might have sounded, to the casual listener, as though she meant they had been refused care, which has certainly not been the case. She tells us what she really means beginning at 5:12–6:30, and I’d encourage you to listen carefully again, and then I’ll explain the sequence of events she is eluding to.
The patients she is referring to were seen. They were evaluated. They were not sick enough to be admitted to the hospital. Because there is no specific medication that has been proven (by large scale studies, not individual anecdotal evidence) to be effective in an outpatient setting, these patients were not prescribed specific therapy. They were likely given recommendations for symptomatic treatment, instructions for self isolation, and guidelines for seeking out a higher level of care if their symptoms worsen; though the thoroughness of those discussions often depend on the time available, the practice style of the clinician, and the degree to which the patient is interested.
So far, this has actually been perfectly appropriate care. Please keep in mind that the hospital is not a place you want to be unless you absolutely have to be. Most patients (85%) with symptomatic COVID-19 have a “mild course.” This can be anything from a mild cough to significant flu-like symptoms which can be very uncomfortable, but most patients with the viral syndrome will not need to be hospitalized. Filling up hospitals with patients who do not need to be there is the wrong decision not just for other patients in the hospital, those who might need to be hospitalized later, and for hospital staff, but also for the patient. It puts everyone at risk, including that patient, and it’s irresponsible. Dr. Lozano states that they were ‘sent home to quarantine, exposing their families’ as though this were a scandal. First of all, if these patients were symptomatic, their families had already been exposed. Second, home is where they would be safest and best taken care of unless they actually needed hospital level care. And third, there are no other viable options. Certainly some countries have set up mobile containment hospitals for mildly symptomatic COVID-19 patients to stay in until they are deemed non-contagious. Please ask yourself if that is something Americans would consent to; being told that even though their symptoms are mild, they cannot be trusted to keep from spreading the virus to others and are not allowed to return to their homes. We can’t even get people to wear masks.
Finally, these patients come to Dr. Lozano, who gives them a prescription for hydroxychloroquine and some unspecified antibiotic shots for good measure. It is now clear that way back at 2:25 when Dr. Lozano said these patients weren’t being treated, what she was really saying was that they weren’t being treated exactly the way they wanted. Now, we could go off on a rabbit trail about antibiotic stewardship and doctors prescribing antibiotics, and other medications, unnecessarily for viral conditions because it makes their patients feel that something has been done. It builds loyalty, it gives them confidence in you, it keeps them coming back to you for minor conditions because they know you’re going to give them something for it; it does everything except actually treat the virus. Please keep in mind that in over half the viral misinformation videos we’ve seen, this is exactly what doctors are being accused of, despite the fact that most of us fight very hard against this exact mentality. It is much, much quicker and easier (and more lucrative, under many practice models) to tell a patient that the injection you are giving them will make them feel better than to carefully, patiently explain that their own immune system will defeat the virus, that there are no specific therapies but lots of things you can do to try to feel better in the meantime, and that your duty is to “First Do No Harm” to them, including prescribing unnecessary and potentially dangerous medications. The latter, in addition to taking more time, also feels unsatisfying to both the patient and the doctor; it’s also the right thing to do. If your doctor never refuses a single thing you ask for, you probably need a new doctor.
What about hydroxychloroquine?
You should know that no medication is “considered a candy” or “a vitamin” (except, you know, actual vitamins). All medications have potential side effects and hydroxychloroquine, while relatively safe, should not be used without a specific indication and a careful evaluation of the risks and benefits. No medicine should.
But even allowing for Dr. Lozano’s waxing a bit eloquent in what comprises the bulk of her arguments in this video, we need to ask some very basic questions about hydroxychloroquine. First, we need to ask whether it works, and second, we need to ask whether her narrative and claims about the medication are true.
Does hydroxychloroquine work?
Because Dr. Judy Mikovits brought up the idea that doctors were being stopped from using hydroxychloroquine in the PlanDemic documentary a few weeks ago, I’ve written about this just recently. In the interest of length I will not reproduce those reflections here. The long and short of it is that the medication showed some promise when it was first used on a small number of patients, and following this it was used widely and we all hoped it would be incredibly effective; but unfortunately subsequent more rigorous trials and widespread physician experience have not shown this to be the case, and now it’s use in COVID-19 has been widely abandoned. For more details, please refer to the section titled “Hydroxychloroquine is a miracle drug” from the blog entry “The Paradoxes of PlanDemic,” or read this article from the New England Journal of Medicine that explains this all in greater detail, and the rationale by which the authors have chosen to stop using the medicine to fight COVID-19.
Claim: Donald Trump taught doctors to use this medicine…
While I’m afraid that I have to consider Dr. Lozano’s claims here to be politically motivated and revisionist, in the interest of fairness I admit that, depending on her individual experiences, what resources she has been using, how she acquires new medical information, and to what degree she was pursuing treatment guidance early in the pandemic, from her own perspective the sequence of events could conceivably appear as she has described them. The French study that originally established the efficacy of hydroxychloroquine for COVID-19 was released in mid march, but there was talk of it being used even prior to this; an article coming out of Wuhan, China was published on March 9th, and by the time of the March 19th press conference where Donald Trump recommended it, all the doctors I know had been talking about it in multiple forums for over a week. I had discussions about it in person and on zoom calls, over text and e-mail, and on social media both on friend’s Facebook walls and in private physician COVID-19 groups. Unless you weren’t paying attention to emerging COVID-19 information (and I think almost all of us were by that time), the president’s mentioning hydroxychloroquine for COVID-19, while certainly contemporary to the discussion, was not breaking news. Though Donald Trump was touting the medication with his usual unmitigated bravado, at the time a lot of us really did feel cautiously hopeful; we really wanted the treatment regimen to be universally effective and live up to the hype as well. We also agreed with Dr. Fauci, who stated that this study was little more than anecdotal, and while promising, shouldn’t be relied on as empirical evidence. This wasn’t a political statement; he was merely bringing to Donald Trump’s enthusiastic endorsement the temper and nuance we would expect from a medical professional. If Fauci’s later being proven right adds fuel to the political fire, it is merely a reflection of how unfortunately politicized this pandemic has become; to medical professionals, the rise and fall of hydroxychloroquine is a normal part of the scientific process, though expedited quite a bit by the pandemic.
But Dr. Lozano goes a step further than even Dr. Mikovits; she really seems to be implying that Donald Trump somehow came across this information on his own. While I understand that is a hallmark of diehard supporters of the president, the desire for him to be the smartest in the room on every subject, the idea that he was personally reviewing medical journal articles and came across this French study independently is really very silly. Of course this information would have been given to him during a briefing by his medical advisors, the same ones who then had to qualify his statements, and the very “bureaucrats standing next to our president” Dr. Lozano later decries for “thinking they know more about medicine than I do.” Notice too this strange juxtaposition; she is willing to stand on her professional pride when confronting Fauci and other advisors to the president with medical backgrounds calling for caution with the medication, calling them ‘bureaucrats’ despite their training; but she is eager to say that the president has taught her how to treat COVID-19.
….while medical societies gave no treatment guidance.
As I’ve said, this French study was published and read and discussed widely in the latter half of March, and many medical associations and news sites offered reflections on it. Treatment regimens were included in the original study, so Dr. Lozano’s saying “you would think I would get some kind of guidance from the American Medical Association” couldn’t refer to needing a hydroxychloroquine dosing schedule, but rather expert opinion on what to do with that already available information. As Dr. Lozano requested, that guidance came out on March 25th. The American Medical Association offered a very measured response, calling for physicians to weigh the evidence carefully and to be ‘just stewards’ of healthcare resources. They reiterated that the French study had been small and only included hospitalized patients, and that medications should always only be prescribed due to an appropriate medical condition. This was in response to reports that some doctors were ordering prescriptions of the medication “for themselves, their families, or their colleagues,” and that some organizations were stockpiling the medication. Indeed, there were reports at the time that some patients with Lupus and Rheumatoid Arthritis were having trouble getting their normal dose of the medication because of this. You can read the AMA’s joint statement with the American Pharmacists Association here; it has since been updated, but a summary of the original from March 25th is also online here.
Claim: Doctors are too scared to use it because it isn’t FDA approved.
The FDA actually issued and Emergency Use Authorization to treat COVID-19 with hydroxychloroquine on March 30th. This is still in effect. The FDA has since issued safety guidelines which also cautioned against its use for COVID-19 outside of the hospital. This is because the medication has many possible side effects including prolonged QT syndrome, which can lead to sudden cardiac death, and because even early evidence only supported use for patients sick enough to be hospitalized, while later, more robust studies have not even supported that. The EUA is still in effect however, which does allow physicians treating extremely ill COVID-19 patients in the hospital to weigh the evidence for themselves.
Why won’t the pharmacy fill these prescriptions?
At 7:36, Dr. Lozano begins the narrative that after her 1st or 2nd or 3rd prescription for hydroxychloroquine, the pharmacist called her to ask for a diagnosis. Dr. Lozano presents this as though it were a conspiracy or scandal, the pharmacist trying to breach patient confidentiality laws. In reality this is very common; knowing the diagnosis is important for the pharmacist for a number of reasons, including counseling the patient appropriately, ensuring that look-alike/sound-alike medicines have not been prescribed on accident (this does happen; I have done it and a smart pharmacist caught the error before the prescription was filled). In fact it is required with certain controlled medications. Your pharmacist is considered to be involved in your care, and sharing your diagnoses with them is not a HIPPA violation if it helps them do their job. Moreover, regardless of Dr. Lozano’s jab that “your job is to put the pills in the bottle,” pharmacists literally go to school for years to study medications; they already know your diagnosis from the medicine alone 99% of the time. No pharmacist is saying, “huh, Mr. Johnson is being prescribed Metformin. I wonder what that could be for?” It’s a diabetes medicine; they know you have diabetes. And that’s fine, because they also abide by patient confidentiality laws and aren’t going to go out and tell people about your diabetes any more than your doctor or nurse would.
With hydroxychloroquine specifically, the pharmacist was likely asking Dr. Lozano for a diagnosis because of the AMA/APhA/ASHP joint statement above, which includes this specific phrasing:
Or maybe it was because of this rule from the Texas State Board of Pharmacy:
So the pharmacist in this scenario was simply following not only the rules of his state governing board but also the consensus advice of the national organizations that represent his profession. Dr. Lozano states that she got around this by eventually finding a pharmacy that would fill the prescription, and by giving them a diagnosis of hypertension or diabetes instead of COVID-19 (it is unclear from her presentation whether these patients in fact have those diagnoses; presumably not, since her whole point is that she is unwilling to share their medical information with the pharmacy). So this requires us to ask the question; are these rules good? Is it reasonable to tell pharmacists that they shouldn’t or can’t fill prescriptions for this medication unless it is for Lupus, Rheumatoid Arthritis, or Malaria? In other words, should this decision really be up to the individual doctor?
In general, physicians tend to be wary of any rule or law that displaces medical decision making outside of the patient-doctor relationship. Dr. Lozano speaks to this around the 8-9 minute mark. The hope is that the years of careful education and training we receive should be sufficient to instill in us the weight of the responsibility we have to follow the evidence and to treat with a light touch in the absence of strong evidence. I believe it generally is. However, there are over a million physicians in the US alone, and oversight and accountability are necessary. As someone who works in the area of opioid dependence treatment, I strongly believe that top-down measures to curb the prescribing of opioids has helped many people avoid addiction and dependence. In the case of hydroxychloroquine, these decisions were made to prevent stockpiling and overprescribing of the medication that would create a shortage that hurt patients who needed it, including those with conditions such as Lupus, and early on, patients in the hospital who were sick enough to be prescribed it for COVID-19.
But it is possible to imagine scenarios where this medication could have been legitimately prescribed in an outpatient setting, at least early on before more data was available. One could imagine a confluence of circumstances where a patient met or nearly met hospitalization criteria, but could not be hospitalized for some reason; being the sole caregiver for a small child and needing to wait a few days for family to return, for instance, or living in a city where the hospitals were full and they didn’t quite meet criteria for hospitalization during the pandemic, even though they might have under normal circumstances. One could imagine a patient in the midst of a work-up for Lupus, whom their doctor was considering starting on hydroxychloroquine anyway, suddenly being diagnosed with a mild case of COVID-19. Would it be legitimate for this to shift the balance of risk and benefit and justify its use now instead of once the work-up is complete? These situations would be exceedingly rare, but they are possible, and it would indeed be frustrating to be a doctor or patient stuck between these realities and the Pharmacy Board’s rules and be unable to get the medication filled.
But is this the case with Dr. Lozano’s patients? Dr. Lozano gave an interview on Fox News where she shares more details from her experiences with the pharmacy. She states, “Yesterday I wrote 5 prescriptions for hydroxychloroquine… Today was horrible, I had 15 people who needed 15 prescriptions.” I have never been in Dr. Lozano’s clinic; I was not there on the day she gave the interview, and cannot vouch for either the COVID-19 status or the severity of illness of her patients. But the idea of one physician in a solo practice seeing 20 patients in 2 days who have COVID-19, and are sick enough that they should have been hospitalized but weren’t, in a city that has only had 6,000 confirmed cases total, is extremely far-fetched. Rather, this paints the picture of a physician who has chosen to simply give the people what they want, and instead of following the evidence and carefully weighing risks and benefits on a case-by-case basis, chose to cultivate a reputation (and client base; she says she has patients driving in her to see her from Austin and San Antonio) by being the doctor who would prescribe the medicine that was suddenly being talked about all over social media after the president’s press conference. Any doctor who suspended their clinical judgement and prescribed hydroxychloroquine for every cough and fever patient who wanted it in March and April could have done likewise; and that is exactly the kind of prescribing practice that the Texas Pharmacy Board rules and the statement by the AMA were meant to protect against.
But what about Dr. Lozano’s experiences with the medicine? Doesn’t that prove it works?
Please listen to what Dr. Lozano says at 7:15.
“I have patients at Lozano Medical Clinic who are cured of this disease. I have patients that recovered within 48 hours. In fact, the illness that they had was more caused by the stress and the fear of the propaganda that’s being spewed on the news media than by the actual virus.”
Dr. Lozano has told us that she prescribed these patients hydroxychloroquine. She has told us she prescribed them azithromycin as well. She has told us that she gave them ‘a few antibiotic injections’ just for good measure. She states that the FDA can approve you-know-what because she has seen patients get better with this treatment. She now tells us she believes most of their symptoms were from stress.
I also have patients who are cured of the virus; their immune systems did that for them. That’s what usually happens with most viruses, and it happens all the same without potentially dangerous or potentially lethal combinations of unnecessary medications. The number of cases where symptoms are so severe that someone needs a high level of support is particularly high for this virus, which is why we are dealing with a pandemic; but they are still in the minority, and Dr. Lozano has offered zero evidence (and quite a lot of counter-evidence) that these patients would have needed hospitalization without the medications she prescribed.
As a physician, I have better tools for treating stress and fear about the virus; compassion, active listening, empathy, and careful explanations of the medical realities they are facing. As far as I know, none of those can cause sudden cardiac death.
“I think when you do things that are incorrect, you need to be thrown under the bus.”Dr. Ivette Lozano
At 10:12 Dr. Lozano throws Walgreens Pharmacy under the bus. She says that if you have a prescription for hydroxychloroquine, Walgreens will call and ask you to fill the prescription in their drive-through instead of at the counter inside. An immuomodulator, for patients who have autoimmune diseases. That is sometimes being used to treat a virus, in the middle of a pandemic caused by that virus. Surely anyone can see that this is a reasonable request?
10:40 “If you are taking a prescription for hydroxychloroquine, they will ask you to come in through their driveway. Well you know what: maybe eventually they’ll ask you to wear a yellow star on your shirt.”
Internet memes and Godwin’s Law aside, this is an absurd comparison. Every clinic I know of has taken steps to ensure that all their patients stay safe during this crisis, and for many that means seeing patients with risk factors for COVID-19 complications and patients with symptoms of the virus outside to prevent transmission. For whichever indication this medication was prescribed, picking it up at the drive-through is a reasonable step to keep both you and others safe. Is this what Dr. Lozano’s audience considers “oppression”? Is this comparable to the Holocaust? I understand that many people are legitimately concerned over the balance between safety during a pandemic and preservation of individual rights, but is going through the drive-through at Walgreens really the Rubicon we dare not cross? To quote one Twitter user:
Dr. Lozano then says that she has encouraged all of her patients to get their prescriptions filled elsewhere, and that gives me the opportunity to share my first financial disclosure in several months of arguing against financially motivated medical misinformation; my father manages a CVS (in a different state than where Dr. Lozano and myself practice). And while that doesn’t actually constitute a financial conflict of interest, on some emotional level I’m ok with Dr. Lozano calling out the competition here, the same way I didn’t like K-Mart growing up when dad was managing Wal-Mart stores. Call it tribalism I guess. In practice, the only time I care which pharmacy a patient chooses to use is when I know they will get a more affordable price somewhere else, and that’s when we talk through their pharmacy options more intentionally.
10:57 HIV vs. COVID-19
Dr. Lozano states that she trained in general surgery during a time when there was not a good test for HIV, so they took precautions with every single case and did not discriminate against people if they had the virus. It seems odd to compare a virus like HIV, which is very difficult to be infected by even through contact with blood, to SARS-CoV-2 which is spread by droplets and airborne transmission. Dr. Lozano is right that no patient should be discriminated against because of an illness, infectious or otherwise. She is also right that we should take precautions to keep ourselves, and others, from becoming infected. But this looks different for different type of infections, based on their infectivity, potential severity, and mode of transmission. Refusing to operate on an HIV positive patient because of their diagnosis would be discrimination; asking a patient with COVID-19 to use the drive-through during a pandemic- which we really all ought to be doing anyway if at all possible- is not.
11:22 “This virus is 98% treatable with no medication! For those 2% who are sick, the President of the United States has given us a phenomenal protocol.”
I’m going to pass over the fact that the president has apparently gone from being told about hydroxychloroquine by his advisors, to reading about it in his independent research, to now actually creating the treatment regimen himself. Fine.
The bigger issue with this sentence is the way that Dr. Lozano has distorted these numbers. Without getting into details about the percentage of patients who need hospitalization and the percentage that need to be in the ICU (these numbers have shifted and will continue to shift as we have better and better data and antibody testing, as physicians and epidemiologists have been saying since the start), we can accept and agree with Dr. Lozano’s point that only a relative few patients with COVID-19 will need intense and specific interventions; as we’ve already discussed most will get better on their own.
But it’s important to clarify two things. First, Dr. Lozano never mentions working in a hospital either in her youtube videos or on her website, only seeing patients in her clinic. I think it’s fair to assume she doesn’t see patients in an inpatient setting or treat critically ill patients in the ICU. This means that the small percentage of patients she mentions who are sick enough to need specific treatments and high-levels of care are not the patients she is interacting with. She has presented a narrative that says most patients get better on their own, so go get your hair cut and go shopping and if you happen to get very sick from COVID-19, go see her and she’ll prescribe you hydroxychloroquine. The reality is that the patients she is prescribing hydroxychloroquine for are the patients who would get better on their own; they are part of the “98%,” not the “2%.” They’ve already been evaluated by other doctors and were told, thankfully, that they didn’t need to be in the hospital. The patients who need the high level of care are actually in the ICU, those that made it there, and are fighting for their lives. Many of those who have had the worst cases and needed that level of care have in fact been treated with hydroxychloroquine, and many of those patients did die; this is where the more powerful and reliable data about it’s efficacy comes from, not from a small clinic that has drastically shifted the definition of ‘very sick’ because it never interacts with patients in the hospital and ICU.
And second, that small percentage of patients, for a virus that is this contagious, still represents an astronomical number of people. This is the same misrepresentation that Dr. Erickson spends the majority of his time on during his interview; the idea that if most people get better it means the virus isn’t very dangerous. Early mortality numbers based only on antigen testing have been in the society-ending range of 4%-12%, but we have known these numbers would come down once asymptomatic or minimally symptomatic cases could be accounted for. If this virus has ‘only’ a 1% case fatality rate, it still has the potential to overwhelm our healthcare infrastructures and kill millions without mitigation strategies. The danger is a product of the per-case risk multiplied by the infectivity, and this virus is both very deadly compared to something like the flu, which is scary enough, and also extremely infectious. A non-dangerous virus could not do to New York and Italy what COVID-19 has done.
“It is not dangerous to go to a restaurant, to go get your hair done, to go shopping.”
Well, it might be actually. I realize things are open now. This virus is very dangerous and unfortunately we do not have a “phenomenal treatment protocol” that renders it harmless. Please make safe decisions for yourself, your loved ones, and your community.