Texas doctors trying novel treatments (the trap of anecdotal evidence).

I’m seeing COVID-19 patients every day.

Last week I saw about 80 patients who had screened positive for either exposure to COVID-19 or possible respiratory viral symptoms; this week more of my time is devoted to working in outdoor COVID-19 testing clinics, so it will probably be well over 100. Some of those patients had been ‘caught’ by our screening questions but really had no COVID-19 exposure or symptoms; the lady with a chronic cough who was really just coming for her high blood pressure, the gentleman with a fever that was caused by an abscess under his axilla (we call it ‘axilla’ because ‘armpit’ sounds so un-doctory). I treated them too, of course. But for the most part people were seen in our COVID-19 focused clinic specifically for COVID-19 related concerns. I don’t have exact numbers in front of me, but of the 70 or so I tested for the virus, about 20 came back positive (Epidemiology note: this is too small of a sample to calculate anything like a test positivity rate or prevalence from), and there were at least a couple that, due to certain combinations of exposures and symptoms, I’m convinced had the virus despite a negative test (way, way too small of a sample to make any calculations from; please don’t go and quote me as saying that based on my sample of 2 out of 50 negative tests I think there is a false negative rate of 4% or something crazy like that)(although now that I look at prevalence estimates and test sensitivity, 4% is actually about right. Hmm…).

I called each patient who tested positive personally to give them the news and answer their questions. Amid the many questions I was asked (‘Should I go to the hospital’?; not now, but let’s talk again about red flag symptoms and emergency precautions. ‘Should I isolate from my children?’; that’s really complicated, and it depends on the age of your children, your support structure, and their specific developmental, physical, and emotional needs), one question that came up over and over again is one I sincerely wish I had a better answer to; ‘what medicine can I take to make sure this gets better?’

This is a big and important question. Doctors kind of like medicine; kind of a lot. After all, prescribing them is a big part of our job, and even though adding a medication is not always the right answer (more on this later), it is incredibly satisfying to prescribe the right medication or therapy for the right diagnosis and then see your patient get better. It can also be fairly stressful at times, because no medication (except prenatal vitamins) is perfectly safe; giving someone a medicine, especially one that wasn’t actually necessary, and then seeing them suffer because of drug interactions or unexpected side effects is devastating to a physician. We have taken an oath to ‘first do no harm,’ and we take it seriously. This is why I’ll spend 10 minutes carefully explaining to a parent about how viruses and bacteria infect the body differently and how antibiotics work rather than spend 2 minutes prescribing their child an unnecessary antibiotic for a viral illness, which would surely feel more satisfying for both of us. It is also why, as certain as I am that some of the patients I have shared the news of a positive COVID-19 test result with will end up getting sicker, and as nervous as that makes me on their behalf, I have not been prescribing unproven, untested medications out of desperation, but have instead focused on teaching those patients how to keep themselves and others safe and how to recognize the early signs of a severe infection.

It’s also why I check for new or updated studies or professional recommendations, and review information being shared between doctors and other clinicians on COVID-19 social media groups every every single. The moment that there is a proven, safe early therapy to prevent COVID-19 infections from becoming severe, I will be the first to start using it.


Dr. Richard Bartlett discovers silver bullet for COVID-19.

Last night I came across a viral video, which has since been sent to me multiple times, which seemed to promise exactly this. A doctor here in Texas went on a morning news show to discuss the 100% effective, perfectly safe COVID-19 treatment he is using to prevent severe illness in his patients. If you have any degree of medical training or even personal experience with medical issues, you are probably just as skeptical as I am about both the ‘perfectly safe’ and the ‘100% effective’ claims; few medicines are ever either. We will go through Dr. Bartlett’s interview in detail below and try to evaluate the quality of data he is relying to make these claims, and answer two questions; should you call and ask your doctor for this ‘new’ treatment, and should I call back all of my patients and tell them, much to my satisfaction, that we do have a medication I can put them on after all?

One quick note: the video is about 30 minutes long and trails off a lot into conspiracy territory concerning mandating vaccines, instituting lockdowns to destroy the economy in order to hurt President Trump’s reelection chances, and quite a few other areas. We’ve covered a lot of that before, and frankly a lot of it falls outside the realm of medical misinformation. We will try to cover the most important parts of Dr. Bartlett’s interview regarding his new COVID-19 therapy, but I won’t try to write the 10,000 words it would take for a rebuttal to all of these ideas.

Here is the video:


00:16: Midland Texas is located in Midland County, about 6 hours West of Waco (golly, Texas really is huge). With a population of 138,000, it is almost exactly the size of Waco. Just like for us and the rest of Texas, they began to see a significant increase in COVID-19 infections about 3 weeks ago. Before this, they had seen very few cases total, like most pre-surge areas. You can review their data here.


00:33: The article is here; it provides some additional details and we will reference it later.


01:48: Dr. Bartlett’s book is entitled Journey of a Medicine Man: Doctor Confirmed Miracles.


COVID-19 in the USA compared to around the world.

At 02:04 Dr. Bartlett begins his discussion on COVID-19 treatment in earnest by discussing the context for the pandemic in America, namely a comparison to both nations that have fought the pandemic successfully and those who have struggled more with a higher number of infections and deaths. He begins with Taiwan.

02:07 “In the country of Taiwan there’s over 25 million people, they’re stacked on top of each other, if they did social distancing they’d be out in the ocean floating around.”

He goes on to say that there isn’t enough room to social distance, and yet the country has seen only 7 COVID-19 deaths, “as many people as you could stack in a minivan.”

The problem here, besides Dr. Bartlett’s strange obsession with stacking people, is that Taiwan has done social distancing. Dr. Bartlett goes on in the video to assert that Taiwan has foregone both social distancing measures and widespread face mask use (which he associates with Communist China). Do any reading on Taiwan’s response to COVID-19 and you will find widespread wearing of face masks and aggressive physical/social distancing measures since the earliest days of the pandemic, in addition to other mitigation strategies such as providing social support for quarantined patients to help them maintain a high level of isolation, and using mobile phone technology to perform extremely precise contact tracing. This is all in the context of a strongly collectivist culture willing to engage in such measures for the good of their neighbors regardless of official mandates, with a history of understanding the stakes in such a pandemic because of their experience with SARS in 2003.

So as Dr. Bartlett moves forward talking about Taiwan later in this video, you need to understand that, perhaps entirely unintentionally, almost everything he has said about their success in fighting COVID-19 so far is the opposite of what they have actually done.

02:41 At this point Dr. Bartlett also mentions Iceland, Singapore, and Japan, who all engaged in some combination of extensive masking and social distancing except Iceland, who used aggressive contact tracing and quarantine measures. Dr. Bartlett’s assertion that they have been successful because they have used similar treatment plans to what he uses for his patients seems entirely unfounded.

02:59 “That’s not possible according to what we’re being told in the mainstream media.”

Literally nobody is hiding this data. If you google “Taiwan COVID” you get this:

“You can even look it up in the Johns Hopkins COVID website and you’ll see those numbers. They’re hidden in there, but I’m pointing them out.”

Hidden” in the sense that geography is hard.

I’m concerned that what Dr. Bartlett is doing here is contributing to a false narrative that the powers that be, especially the CDC, the WHO, and the medical establishment (i.e. he and I), doesn’t want people to have access to good reliable data. Maybe this is where Dr. Bartlett’s search for reliable information to back up his COVID-19 treatment has led him; not trusting the available information because he wasn’t able to find the scientific verification he is sure must be out there for his new therapy. Maybe this is strongly ingrained in his political position (he recently ran for office) and he is interpreting the ready availability of this kind of data through a lens of suspicion, or knows that his audience on this show will affirm the idea that this information is being hidden from them and that it is harmless to reinforce that belief. But I am always a little suspicious of physicians who want to weave these tells of conspiracy theories and hidden truths about the pandemic while promoting their own unverified findings, and part of me wonders if they are certain they will face pushback from their fellow doctors and scientists, and want to head it off at the pass by encouraging the idea that those doctors and scientists don’t want you to know ‘the truth.’ I certainly hope this isn’t the case with Dr. Bartlett, but part of me thinks it must be an easy trap to fall into without realizing it.


It isn’t Hydroxychloroquine

03:32 “(In these other countries) they’re doing what I’m doing, which is not hydroxychloroquine, although that works….

Before he reveals his miracle drug, he gives a brief shout-out to Hydroxychloroquine, stating it does work but not providing further explanation as to how he knows it does or why he doesn’t use it as well. I almost wrote today about a viral post by a doctor in McKinney Texas again promoting outpatient, widespread hydroxychloroquine use in patients regardless of test results and risk factors. We covered this pretty extensively over a month ago following his colleague Dr. Lozano’s speech at the Set Texas Free Rally in Dallas. He also claims that masking, social distancing, and even testing are ineffective. I’ve chosen to write about Dr. Bartlett’s video instead, but in terms of relying on anecdotal evidence and not understanding representative sample sizes, there are a lot of similarities. If things are quiet this week I will try to write about Dr. Procter’s social media post as well and try to tackle hydrochloroquine one last time.

I want to talk hydroxychloroquine.
I want to talk about these scripts that you’re writing;
Put down the pen, stop prescribing.
I want to talk about what I have learned,
About the research you have spurned…


The Silver Bullet: Inhaled Budesonide

03:36 “So what they’re doing is an inhaled steroid. So my silver bullet is inhaled budesonide.”

Dr. Bartlett finally reveals his miracle drug, inhaled budesonide; a commonly used inhaled corticosteroid that is commonly used for patients with Asthma or COPD.

This is the first good place to stop and look at this idea in more detail. The first two questions we need to ask when someone proposes a novel use of a medication or therapy are 1. Is there a proposed mechanism by which this would work? 2. Why did nobody else think of this (has this been tried/studied before)?

Dr. Bartlett’s rationale is that since this is an inhaled respiratory anti-inflammatory, it should work for COVID-19 which is a ‘respiratory inflammatory condition.’ Part of the problem here is that this is gross oversimplification of the virus’s pathophysiology, which is still not completely understood (see below). It is supposed to make you go “wow, that’s just common sense! It causes inflammation in the lungs, so an anti-inflammatory breathed into the lungs will cure it!” But if you reflect on whatever extent of experience you have with medicine, you will realize that things are never quite that simple. If you came to me for your severe, debilitating back pain you’ve been struggling with for years and I said, “oh I’ve got it, back pain is caused by inflammation of the muscles and joints, so I’ll give you a medicine to decrease inflammation; here’s some ibuprofen,” you’d probably lose a great deal of respect for me. You’d be right to. NSAID’s (non-steroidal anti-inflammatory drugs, like ibuprofen) may well be part of your treatment plan, but your back pain is complicated and is going to require more thorough evaluation and treatment. In medicine, you are right to beware of easy answers.

Sentences like these are why I went into clinical medicine.

Budesonide is a common medication, as he points out repeatedly beginning in a few minutes, and I think this is actually the strongest argument against his proposed use of it in COVID-19. You read that right; I’ll explain. The usual dosing of budesonide is twice a day as a maintenance medication; by decreasing inflammation and swelling in the airways, it can eventually (it may take weeks to months) lead to less frequent asthma and COPD symptoms like cough and chest tightness, and fewer exacerbations. However, Asthma and COPD patients still have acute exacerbations despite using inhaled corticosteroids. We still see patients on budesonide in the clinic and in the hospital for acute worsening of their symptoms due to respiratory infections. Sometimes these are bacterial infections, but more often they are viral; including coronavirus species. Sometimes these patients go into respiratory distress, and sometimes die, even when the virus they have isn’t nearly as deadly as COVID-19. If budesonide was able to completely prevent viral respiratory illnesses from causing inflammatory respiratory symptoms like cough, shortness of breath, wheezing, and chest tightness, we would never see these patients getting sick from respiratory viruses; but we do, because the medication doesn’t really work that way. If Dr. Bartlett consulted his complex understanding and professional history of treating respiratory infections he would realize that his proposed mechanism really doesn’t make sense, especially as the 100% effective silver bullet he is promoting it to be.

Later in the video (around the 06:36 mark) Dr. Bartlett does talk about the “cytokine storm” in COVID-19 and prevention of the body’s own inflammatory response to the virus. Is it possible that the medication he is using, while not preventing all respiratory viral infections, at least treats this one? Without getting into the weeds too much here (the idea of a cytokine storm being the underlying cause of ARDS in COVID-19 is still controversial), we need to understand that you don’t just have this one thing called ‘your immune system’ causing this process called ‘inflammation’, so that if ‘inflammation’ (or in this case, ‘cytokine storm’) is the problem we can just suppress the immune system and call it a day. The immune system is incredibly complex, and any given immunomodulating medication is going to work on parts of the immune system (and not always in the ways we hope or expect) while not significantly affecting others. As an example, the primary cytokine implicated in the COVID-19 cytokine storm seems to be interleukin 6, a pro-inflammatory cytokine that budesonide, in previous studies unrelated to COVID-19, doesn’t seem to affect appreciably. Studies focused on medications that do appreciably decrease IL-6 activity are currently underway.

I’m having bad flashbacks to 2nd year of med school right now.

The second question, if the mechanism did make perfect sense, would be to ask whether anyone has tried this before. Dr. Bartlett indicates that it has been tried elsewhere; he states that this is what they are doing already in Taiwan and Singapore. I was unable to substantiate this; I cannot find any evidence that these nations have used anything like widespread protocols with inhaled steroids to treat COVID-19 early in the disease course. There are some ongoing trials with use of inhaled corticosteroids (not budesonide, at least that I could find), as Dr. Bartlett mentions, but there is not any data available from them yet; if they prove safe and beneficial for COVID-19 patients, we would start using them in all the clinical contexts where they were shown to be effective.

There are two other data sources we could look at. First, the most successful trial we have right now with use of steroids in COVID-19 is the RECOVERY Trial out of Oxford, which I wrote about recently. In this study patients were put on systemic steroids (dexamethasone) once they were already hospitalized. You might argue that this isn’t what Dr. Bartlett is talking about at all, that he wants to use budesonide before they are sick enough to go to the hospital. I understand that; but the study showed a reduction in mortality in both the groups needing oxygen and those requiring mechanical ventilation, but not in those who didn’t require oxygen. You can only extrapolate so much from this, but if Dr. Bartlett’s theory of the earlier the steroids the better panned out, you would expect the non-oxygen group to see at least as much improvement in outcomes as the patients who were already very, very sick; but that wasn’t the case. We need to remember that even though our first successful randomized drug trial for COVID-19 is indeed a steroid, the role it plays is complex and the benefits limited to certain clinical scenarios; the data still shows that immunocompromised patients, including those on medications that modulate the immune system, are at a higher risk for COVID-19 than those who aren’t.

We can also look at the two closest viruses to COVID-19 that we have experienced, SARS in 2003 and MERS in 2012. These are both Coronaviruses that seemed to involve a ‘cytokine storm’ causing acute respiratory distress syndrome. During these outbreaks inhaled corticosteroids were used more widely, but results were mixed; there was no strong evidence of benefit, and some evidence of worsening of the disease, including increased risks of secondary bacterial pneumonia and prolonging the time it took for the body to clear the virus.

Edit: When discussing this issue, a colleague also pointed that this idea of ‘what about decreasing inflammation in the lungs’ is not novel, and studies have tested inhaled corticosteroids on practically every lung infection (infection is a very pro-inflammatory state) over the past 30 years, not just SARS and MERS. Results have been extremely unimpressive, but there has been consistent evidence of increased risk of certain types of lung infections, including tuberculosis, non-tuberculosis mycobacterium infections, and severe drug-resistant bacterial pneumonia.

So I’ll conclude this section where many people with much more expertise in this area than myself have, by saying that the balance of risks and benefits still doesn’t justify use of an inhaled steroid in people without asthma or COPD who are already taking one or would benefit from one anyway. There is no reason to believe that they will appreciably decrease the chances of developing the severe acute respiratory distress syndrome that makes the virus so dangerous for some people, and for the vast majority of people who will do fine with their own innate immune system fighting the virus, steroids would potentially increase both the risk of worsening infection and delayed clearance of the virus, and the risk for associated bacterial infections (in addition to a host of other potential side effects). If we were to begin using this in patients who don’t have COVID-19 as prophylaxis, we could conceivably increase their likelihood of getting the virus. The mechanism of causing these types of harm is at least as strong as the proposed mechanism of preventing worsening of the disease.


03:46 “It’s super cheap, it costs about $200 for the total treatment if you pay cash.”

I understand that he is probably intending this as a comparison to a hospitalization for COVID-19, which is disastrously expensive, as he truly believes the budesonide will prevent hospitalization. Still, all I can say is that Dr. Bartlett and I have different ideas about what constitutes super cheap medication; most of my patients could not afford a $200 medicine.


“But what does all of that matter? He said it is working for his patients.”

There are some more problematic statements in this video, including the idea that our numbers in Texas are only going up because of increased testing (17:05), revisionist statements that totally invert the sequence of events and thus cause and effect of social distancing and masking measures in the most affected countries (21:50), a troubling statement about Japanese people ‘crawling all over each other in Sushi bars’ (22:55), and strangest of all, repeated statements about how waiting to treat someone until they have symptoms is un-American, whereas early treatment is the American way (both preventative and acute care are part of every healthcare system in the world; there is nothing particularly American about throwing medications at people before you know whether or not they need them).

I hope to update this post with some rapid-fire answers to these issues later, but I want to focus here, for now, because I sincerely believe this is the part of Dr. Bartlett’s interview that people find most convincing.

“One hundred percent of my patients are alive. I’ve been treating this since March.”

I’ve written before about the dangers of anecdotal evidence. I think as physicians we are prone to fall into this trap for a couple of reasons. One is because we want so badly to help our patients, and if we hit on a medication that really feels like it is working, it’s hard to let go of that feeling. Another is because we spend so much time thinking about our patients and working for their well-being that their stories loom very large in our minds, and it’s easy for the relative importance, as data, of our personal small numbers of cases to become overinflated. With that in mind, I think it’s worth looking at Dr. Bartlett’s evidence from the outside and asking whether it really has the value he credits to it.

According to the local news article featuring Dr. Bartlett back on May 21st where he first publicly called budesonide his ‘silver bullet’ against COVID-19, at that time he had treated 12 people. Twelve. This is an incredibly small sample size, but we could hardly expect larger; Dr. Bartlett is not the only doctor in Midland, and throughout March, April, and May the entire county only had 1 or 2 new cases of COVID-19 most days; there just weren’t that many COVID-19 patients to go around. Dr. Lozano had previously gotten around this issue by saying that she wasn’t even testing, but was treating empirically based on symptoms or possible exposure, which doesn’t really make sense in a pre-surge area with incredibly low prevalence. Dr. Bartlett has stated that he believes in testing, and although his comments are mixed on whether he is treating only confirmed COVID-19 cases with budesonide, I think we could credit him with such qualms. Twelve cases over 3 months is an extremely small sample size, and it is important that we understand that this is not coming from someone who has been inundated with COVID-19 cases like our peers in New York; at the time that Dr. Bartlett decided that budesonide was a miracle drug he had practically no experience with the virus. It is certain that his numbers have come up by now, with cases rising all across Texas; but with lag time between exposure and the onset of symptoms, and a second lag between the beginning of symptoms and severe respiratory complications, it is not possible to say that all of Dr. Bartlett’s recent COVID-19 patients are out of the woods yet.

So Dr. Bartlett’s first error is over valuing the data from his sample size, but his second error is in thinking this disease is more dangerous than it actually is. I know that seems like a strange thing to type; the disease is plenty dangerous, and I have encouraged the utmost caution on this blog more times than I can count. We have looked over and over at the hundreds of thousands to millions of lives that might be lost if we do not discover effective drug therapies and if the virus continues to spread unabated because of poor adherence to mitigation strategies like face masks and physical distancing. But the virus has never been estimated as having a 20% fatality rate as Dr. Bartlett says in the video. Dr. Bartlett has no doubt been worried about COVID-19 since March, just like me. Just like me, he probably has friends and classmates working in ER’s and hospitals in New York and New Orleans and other areas that have already been hit hard, and has heard the horror stories about what this can do to both individual patients and entire healthcare systems. Like me, as soon as he started thinking about this respiratory virus he probably immediately thought of the names and faces of two dozen patients that he was particularly worried about. Due to this anxiety, surviving the virus has become, in his mind, the exception rather than the rule. We see this in his account of the woman battling cancer; he says “she should die according to what you hear from the CDC and the WHO,” even though we know that COVID-19 is not universally fatal for any group. By increasing the danger of the virus in his mind, or at least increasing the probability that any given patient will go to the hospital or die, it makes it seemingly unlikely for people to get better without some specific intervention, even though we know that is what happens most of the time; thus the interventions he has chosen (budesonide, zinc, antibiotics) receive the credit for his patients’ recovery.

Put these two biases or statistical errors together and it may be easy for a physician to believe, based on the slightest of clinical experience with this virus, that he has discovered a cure. Each patient you treat this way will confirm it for you, as long as they get better, even if they would have gotten better anyway, and particularly if they tell you they feel better right away, which is such a wonderful feeling even if it doesn’t always correlate to their eventual outcome. If you are willing to loosen your treatment criteria to include people who have had no test or negative tests, or who are fully asymptomatic as Dr. Lozano seems to have done with hydroxychloroquine, you can inflate your treatment numbers even higher. And if you top-out at something manageable for a small-town physician, say in the low 100’s, you might never see a fatality from COVID-19. Imagine that we were back in May when Dr. Bartlett had only treated 12 COVID-19 patients. He states boldly that 100% of his patients were alive, yet we think the death rate is around 1.3%. If just one of his 12 patients had died we might still find this convincing because we are so easily swayed by anecdotal evidence, but that would have been a fatality rate of 8.3% in his budesonide patients. We would have fallen into the same trap as Dr. Bartlett, of picturing those 12 patients heading toward certain demise and all but one rescued by his treatment plan, without which they would have died, when in reality there is no evidence to suggest that they would have been any worse off without the treatment. Dr. Bartlett’s experiences with the virus so far are exactly what we would expect without budesonide and antibiotics.


“Look, he says it is helping his patients and you don’t have to use it for yours, so why does it matter to you?”

Great question, hypothetical person who keeps arguing with me on the internet. Any time we begin talking about someone’s personal experiences, the temptation is to treat their narrative as incontestable; I wasn’t there, I didn’t see his patients, so I don’t have the ability to second-guess his clinical judgement. In a way this is actually sort of fair; Dr. Bartlett had just as many years of medical school and residency as I did, and has many years more clinical experience, and to some degree each physician has earned a degree of professional trust to practice in a way we see fit with accountability only to ourselves and our patients, at least in many circumstances. But we know that this professional leeway has been abused in the past, and even in the absence of abuse of that privilege, lone-wolf medicine is a real problem because by it’s very nature it is disconnected from one of the best tools we have to improve our clinical abilities and correct our errors; the honest feedback and accountability of our fellow doctors. If a physician feels that a patient’s clinical situation calls for a unique approach that is not supported by evidence, this can often still be tried as long it is accompanied by an honest and careful explanation to the patient of the reasoning behind this approach, the unproven nature of the treatment, and the risks involved. If we begin to make a habit of such practices, and particularly if we do so ignoring the voices of our peers around the world saying we’ve tried this before and it didn’t show reliable results on a larger scale, or the voice of researchers and scientists saying that doesn’t actually work the way you think it does, then we are doing so at our own, and more importantly at our patients’, peril.

In many ways I think Dr. Bartlett is actually going about this fairly well. He seems to imply that he is using the medication, which does have a theoretical mechanism of action after all, only on those who really do have COVID-19. He does not seem to be doing television interviews or talking with newspapers in order to make a name for himself and attract clientele from all over the state to help his business, as seems to be the case with some other doctors prescribing unproven treatments, but in order to ‘get the word out there’ to other doctors (as one of those other doctors, I deeply appreciate this impulse), although I am not sure why he has not utilized any of the many avenues on social media that many of use are using to get physician specific feedback and share ideas; maybe he is and we just aren’t part of the same COVID-19 doctor groups. Most importantly, he states that he has written and is submitting a paper for publication, which will provide both more details about his patients, their demographics, commodities, and clinical presentations, and allow for peer review and a higher degree of detail and scrutiny than we could possibly get through a TV interview.

But there are at least three ways (besides the tacit endorsement of several conspiracy theories) that I find Dr. Bartlett’s approach truly troubling. First, he is not presenting his treatment plan as an entirely unsubstantiated experimental approach driven by hope and a hunch, which is what it absolutely is, but as a “Silver Bullet” that is perfectly safe and cannot fail, which is certainly is not. One would hope that this is bravado or enthusiasm for the TV audience and not hubris; in other words, we have to hope that whatever confidence in his treatment regimen he shows in this interview, he is still very carefully explaining to his patients the limitations of his evidence and the potential risks they are taking on if they use it, and the red flags to look for in case it doesn’t work.

Second, he is not just promoting his unproven treatment but also discouraging mitigation measures, such as physical (social) distancing and wearing masks, that actually have been proven to save lives. It is unclear whether he believes the misinformation around these strategies not working or is just so confident in his treatment approach that he no longer thinks they are necessary, but the effect will be the same; as Dr. Bartlett’s video goes viral there will be increased pushback against wearing masks and observing distancing measures by those who find him convincing, which will ultimately lead to more cases, more hospitalizations, and more deaths. His evidence is too weak and his scientific rationale too shaky to convince a conscientious doctor to start using his treatment approach; but he speaks with enough confidence and sincerity to convince some people on the fence not to wear masks. The net effect of his interview, like any viral misinformation, is to make the pandemic more dangerous for everyone.

And third, by presenting his treatment plan as something that it isn’t and ascribing to it all of the confidence and reliability of a truly proven treatment, he is spreading misinformation that blocks out the transmission of reliable information for the public and pollutes the relationship between his listeners and their own doctors and healthcare systems. When I explain to patients that I do not have a proven medication I can in good conscience prescribe them to prevent their COVID-19 from progressing, their exposure to voices like Dr. Bartlett’s, Dr. Lozano’s, and Dr. Procter’s have already sewn the seeds of mistrust in the information I am providing, and they are less likely to believe the other recommendations I am carefully trying to give, such as isolating within their home and monitoring for red flag symptoms, and the reassurance I am trying to provide to alleviate their fear and anxiety as we discuss their individual chances of having a severe course of the virus. It may lead anxious patients to seek additional visits elsewhere and shop for a doctor that will prescribe them what Dr. Bartlett says they need, further increasing their chances of exposing others and potentially increasing the costs associated with their medical care, both to them personally and to an already strained system. It may even lead some patients, convinced by these doctors and desperate for medicines they now believe are their only hope of beating the virus, to misrepresent their symptoms in ways they think might push their doctor into prescribing them.

When lone wolf doctors promote unproven therapies and set themselves up as experts with miracle cures, without having actually done the clinical research to validate their claims, it erodes the fragile trust that we work so hard to build with our patients when we are unwilling to engage in that same type of speculative treatment. This unearned mistrust has the potential to breakdown the patient-physician relationship and affect our patients’ health for years to come. Millions of doctors, nurses, and other medical professionals around the world are working as hard as we can to both care for our patients in the midst of this pandemic and stay up to date with the latest diagnostic and treatment options. Viral voices drowning out the excellent work that is being done researching potential treatments, and calling out any doctor not willing to follow their lead, should humbly re-evaluate their limited clinical experiences in the face of this global pandemic and bring forward their innovations, not with less hope or enthusiasm, but with much more care and a realistic appraisal of the strength, or lack thereof, of their evidence.

On Masking

I had intended to write this weekend on a variety of topics, including herd immunity, the recent RECOVERY trial using low-dose dexamethasone in critically ill COVID-19 patients, antibody testing, and the question of whether the increase in cases is really just due to increased testing (answer: unfortunately, no). But when I woke up this morning the world seemed suddenly, vehemently, and inexplicably divided on just one subject: wearing masks.

Part of this can be accounted for, at least locally; yesterday the City of Waco issued an order requiring businesses to create and post mask policies for employees and customers. As with anything that has been unnecessarily politicized and sensationalized, I recommend you read for yourself what the order actually does and does not require. This morning I had half a dozen messages asking for my thoughts on whether or not masks are an effective strategy, and several people shared pieces of misinformation they wanted to bring to my attention.

So while I would still like to write about all of the above issues, I think this one will have to take priority today.


Are masks safe and effective?

G.K. Chesterton said that he was most convinced by evidence that is ‘miscellaneous and even scrappy.’

“A man may well be less convinced of a philosophy from four books, than from one book, one battle, one landscape, and one old friend. The very fact that the things are of different kinds increases the importance of the fact that they all point to one conclusion.”

G.K. Chesterton, Orthodoxy

So while we will look at scientific studies, journal articles, and other medical evidence, I want to include data from various kinds of research, including both laboratory conditions and real-world epidemiology, and from both prior to and during the COVID-19 pandemic. I also want us to apply some common sense and a good bit of our own past experiences. This can be dangerous in a field like medicine, where realities are often counter-intuitive, but if undertaken cautiously this common sense approach can serve as an anchor for the more academic information.

With that in mind, I think we can start by thinking about the advice we give to children when they are sick or have seasonal allergies (if your children are like mine, these efforts are ultimately futile, but struggling against that futility is a time honored parenting tradition). We tell children to place their hands over their mouths when they sneeze or cough. If we are particularly savvy (and can get past the occult theme; looking at you anti-Harry Potter friends), we teach them the Vampire Sneeze/Cough, where we cough into the antecubital fossa (the bend of the elbow) instead of our hands.

It does work much better if you wear a cloak at all times.

Why? Because respiratory viruses are spread through respiratory droplets; mucous and saliva from the respiratory track that contains the virus. In this article we will look at the filtering ability of various types of masks and whether they are actually able to catch the microscopic particles that cause illness, but you don’t need a microscope to measure the number of microns between a toddler’s fingers when she almost but not quite entirely fails to cover her mouth for a cough; it’s a lot.

Now it’s true that these etiquette maneuvers do not actually stop or absorb all of the particles; they catch some and merely redirect others into the surrounding environment. But you knew that. If you live with a sick child, the odds of yourself or another family member getting sick is high regardless of how good they are at vampire coughing. The goal isn’t to stop 100% of the droplets, but to modify the spatial distribution; to make it less likely that you will get sick from someone coughing or sneezing a few feet away or across the room. Even in science some things are intuitive; if you can feel the spray of respiratory droplets on your face when someone coughs near you, you know your chances of getting sick are higher.

This is the same principal we are talking about when it comes to masks. Nobody is saying that if someone has COVID-19 they can just wear a mask, N95 or otherwise, and cough and sneeze without getting anyone sick; studies have show that the particles still escape. But if someone coughs across the room from you, their mask or their elbow, or even better both, interrupts the momentum of the droplets (50 mph for a cough, 100 for a sneeze according to a study in the Journal of Fluid Mechanics) and decreases the chances of the droplets reaching you, giving you time to move away or at least cover your own face, blocking a few more particles. These are components of an overall risk mitigation strategy that involves things like social and physical distancing, frequent hand washing, sitting outside instead of inside, contact tracing of COVID-19 patients, and staying home if you are sick.

Masks aren’t perfect, but nobody is claiming they are.

It’s also important to note that the studies that have shown only very modest benefits of masks, such as the study that produced the graph above, have focused on the spread of droplets through coughing and sneezing; high pressure, high velocity events that force droplets through and around barriers such as masks and sleeves. However, the City of Waco is not asking 100,000 people to wear a mask in case one of those people happens to cough in HEB. We now know that both asymptomatic and presymptomatic COVID-19 transmission do indeed occur, and the mechanism of transmission still seems to be from saliva and respiratory mucous, including respiratory droplets and aerosols, even in the absence of coughing and sneezing. Talking, forcefully exhaling, singing, yawning, spit talking; all of these are lower pressure events where a mask may actually block, rather than redirect, a higher percentage of these small, lower velocity particles. Again, you already believe this intuitively, because you cover your mouth when your breath stinks.

Or you should.

I also think that revisiting our actual real life experience and common sense is particularly important when dealing with medical misinformation, which is often found to be self-contradictory and manifestly illogical within only a few moments consideration and comparison to facts we already know. It rarely takes being a physician or another scientist to figure out that these wild claims on social media aren’t accurate, though I’m sure it helps.


Unmasking Mask Misinformation (sorry)

A friend sent this to me this morning; it was posted on a public forum (“public forum” sounds so much more legitimate than “Facebook comments”) as a response to our city’s new masking policy. I’ve also been sent a longer paragraph format piece that starts “I am OSHA 10&30 certified.” Since they overlap quite a bit, I won’t re-post that one in its entirety, but it’s just full of contradictions (‘surgical masks only filter on the exhale’ yet ‘become useless’ for protecting you if your breath clogs them), false claims (‘N95 masks can’t filter COVID-19’, ‘asymptomatic spread doesn’t occur’), and nonsensical statements (if you wear a mask and get exposed to COVID-19 you become a walking virus dispenser, cloth masks are worse than no barrier at all). It does make one really excellent point though; if you are relying on wearing a mask to fully protect you from getting or spreading COVID-19, that is indeed a false sense of security. We can’t say that often enough; but it just doesn’t follow that masks are worthless or make the problem worse, which is what they repeatedly claim. I’d like to go through the claims above in order, before concluding with some final arguments for masking.


Claims #1 and #2: Masks decrease oxygen intake and increase carbon dioxide retention.

This is something that has been studied extensively, and there is no evidence that simple surgical or cloth face masks will cause hypoxia or any significant decline in oxygen levels. Oxygen molecules are very small and diffuse easily both around and through these types of masks; they are nowhere near the size of viruses, or the much larger respiratory droplets that carry most of the virus that is exhaled. The same is true about Carbon Dioxide, which is only slightly larger.

But you can also consult your own experience here. Many types of people already wear masks for many hours of the day, from surgeons to certain industrial workers, and women in many cultures wear face coverings as a part of their public clothing. Yet we do not consider these persons to be at high risk for either hypoxic (low oxygen) or hypercapnic (high CO2) injury. A big part of the problem is that we have sensationalized the wearing of masks during COVID-19 and have started to treat it like it isn’t a normal part of our experience already, which it absolutely is. Whether it is the above examples, or Halloween or Comic-Con, or my 5 year old spending three weeks straight in his Spider-Man costume and refusing to wear anything else, the wearing of masks is something we all have some degree of experience with and have never really been concerned about until now, when we are suddenly being told they are extremely dangerous, generally by the same people who have been spreading various types of COVID-19 misinformation since mid-March.

But more to the point, you can study this on your own. A battery powered pulse oximeter is very accurate and costs about $12, and you can use one to do a simple experiment that will reassure you, at the very least, that your face mask is not causing your oxygen levels to drop. Check your oxygen level with your mask off, and then wear it for however long you expect to need it when you are out running errands or whatever scenario you are worried about. Then check it again. In general in a healthy adult, readings above 95% are normal and below 90% are concerning. As an example, I’ve been wearing my properly fitting N95 for the last half-hour and my O2 saturation has fallen exactly one percentage point.

I’ll admit, I freaked out for a minute before I realized the labels are upside down.

There is one group of people we should mention here, and that’s people with chronic lung disease such as COPD or Asthma. For people with these conditions, the increased heat and moisture of the air within the mask, and the decreased air flow directly to the nose and mouth, really can create both real and perceived difficulty breathing (and in these conditions, these trigger each other so easily that drawing a distinction between the physiologic respiratory distress and the anxiety-provoked sensation of respiratory distress is almost a false dichotomy; not being able to breath is scary). These are also conditions that predict a higher likelihood of severe illness in COVID-19, which complicates matters. For these individuals who should already be taking every precaution possible for their own safety in the midst of this pandemic, the decision of whether and what kind of mask they should wear when they do have to go out should be a discussion between them and their doctor. For the rest of us, especially those of us who personally care about someone with Asthma or COPD, it’s important that we take every precaution we can; it should go without saying that our “what about someone with a chronic respiratory illness” should only ever be a legitimate question on their behalf, not a rhetorical ‘gotcha’ to turn off our intellectual honesty on this issue and dismiss the benefits of everyone else wearing a mask.


Claims #3 and #4: Masks shut down the immune system and reactive your own viruses.

The third claim, that masks shut down your immune system, is just a reiteration of the above two, and there is absolutely no evidence for it. As we’ve already said, doctors, nurses, and other medical professionals, and especially those involved in surgery, wear masks all the time without any fear of their immune systems being shut down or weakened. And while these types of people are often fearless when confronting deadly situations or illnesses in order to care for their patients, as we have seen throughout this pandemic, they tend to otherwise be fairly health conscious. I still remember being shocked during a group discussion in medical school when we were asked what it was we valued most highly. I was trying to honestly wrestle with whether I valued my faith, my wife, or my daughter most, and how it was even possible to separate those things from one another, when my friend answered “my health,” and several others nodded in agreement. I have no judgement for that person, but the whole idea was very alien to me (and maybe that shows something of my privilege in having lived overall a very healthy life, often despite my personal choices). Maybe this friend would risk the thing he valued highest on behalf of a patient (in fact I think he would); but if there was any evidence that his health was imperiled by wearing a mask, he would be leading the charge against masking (just checked facebook; he isn’t), and probably would have been doing so since medical school.

The fourth claim is one that I first came across in the Plandemic “documentary” last month, and based on the wording it seems to be taken directly from there (or they are both taken from a 3rd, unknown source, which I’ll call “Q”)(I’m now being told that “Q” is already taken). The actual claim is that wearing a mask will activate dormant retroviruses that live in your body. Retroviruses are a family of viruses that replicate by inserting viral DNA into host cells and hijacking cellular machinery, and only a few known species causes disease in humans, including HIV and Human T-Lymphotropic Virus, which can cause certain cancers. This claim is very specific and very conspiracy-theory oriented, but I suspect that this distinction between retroviruses and common viral illnesses like cold and flu is not being made by the people spreading this meme.

The long and short of it is that this just isn’t the way the immune system works. You don’t have a host of dormant viruses sitting in your lungs that, if breathed into a cloth or small space and then breathed in again, will suddenly become active and cause an infection. Do you get sick when you sit in a car? What about when you hold your breath? What if you sleep with your face too close to a pillow? Is there evidence that we see more respiratory infections in people that wear masks regularly? Of course not. In someone who has a functioning immune system, once your immune system has seen and defeated a virus, you cannot give that virus to you; you already have an effective immune response to it. There are a small number of exceptions, like getting shingles through varicella zoster reactivation, but coronaviruses aren’t one of them and there is no evidence that wearing a mask or breathing out and then breathing in the ‘same air’ has anything to do with viral reactivation; there isn’t even a physiologic mechanism that would make this possible.


Claim #5: The virus is too small to be trapped by the masks!

This is where both the misinformation and the answer get a bit more technical, and if you want all of the scientific details, the blog First10em has an amazing article on masking, viral transmission, the 6 feet apart rule (which they call the “2 meter” rule, whatever that means), and the transmission patterns and particle sizes of both droplets and aerosols. The question of whether various types of face masks besides N95’s actually do filter the COVID-19 virus itself is still an unanswered question, but the answer seems to be, to some degree, yes. Studies have shown different types of masks to have varying filtering efficacy even down to to very, very small particles in the range of 300 nanometers or less, in fact right in the range of the virus itself (the SARS-CoV-2 virus is roughly 120 nanometers; an earlier version of this article incorrectly reported the size of the measured particles in this study as 40 times smaller than the virus, which was just due to me getting my conversions wrong. Sorry; pay attention in 8th grade algebra, kids), but other studies have shown that the virus is still able to transmit through (or around) masks, at least to a few inches away and if propelled by a cough. Taken together these studies seem to reiterate what we have been saying all along; masks aren’t perfect, but they do decrease the risk, especially in short-term contact with non-cough, non-sneeze related transmissions like we would see in asymptomatic and presymptomatic cases. Indeed, this is confirmed by a Hong Kong study in 2011 that found that the protection offered against respiratory pathogens by all types of face masks decreased with higher velocities and prolonged exposure.

Again, Oxygen molecules are < 0.5 nm

Regarding this piece of misinformation though, we can summarize the two main errors pretty succinctly; the virus isn’t floating through the air by itself, it’s suspended in respiratory droplets and aerosols; and the masks aren’t supposed to block 100% of the particles on the microscopic level (though that would great), just trap most of them and slow the others down. The mosquito through a chain link fence analogy is silly because mosquitos can fly around barriers volitionally, and because it uses the size of the virus instead of the size of the respiratory particles, which are much larger (1-100 microns, mostly, instead of 0.12 microns). But if you want to use the analogy, it’s more like hitting golf balls through a chain link fence; yes, the gaps are bigger than the golfballs, and some will go through if they are hit really hard; but many will be blocked outright and many others will be slowed down and redirected.


Claim #6: There is no evidence to support masks.

We have already looked at some of the various types of evidence that I believe we all find somewhat convincing. We believe as a culture that masks are least helpful in preventing infections in some situations, such as surgery, and believe they are safe when we wear them for cultural or religious reasons, as part of our jobs, or as part of costumes. We engage in barrier maneuvers (some better than others) to block large respiratory droplets when we cough and sneeze. We know the masks redirect and lessen such droplets even in these high-velocity conditions, and we’ve seen the evidence from physics and fluid dynamics studies that they can filter the smaller aerosols under low-velocity conditions. For me, the last remaining piece of the puzzle is, “does it actually work, really?”

I want to look at two more types of evidence; epidemiology evidence from before the COVID-19 pandemic, and emerging epidemiological data from right now. An Australian study in 2009, well before the COVID-19 Pandemic (but you knew that), found that the wearing of face masks did diminish the transmission of upper respiratory illnesses even among household contacts, but that there were fairly low rates of compliance with masking. If masks were worn more, they could help significantly.

“Adherence to mask use was associated with a significantly reduced risk of ILI-associated (Influenza Like Illness) infection. We concluded that household use of masks is associated with low adherence and is ineffective in controlling seasonal ILI. If adherence were greater, mask use might reduce transmission during a severe influenza pandemic.”

This study and others like it, 10 years prior to the COVID-19 pandemic, should at least put to rest any ideas that wearing masks is a novel recommendation or a government ploy to control yet another aspect of our lives. Masks have been recommended, and shown to work, for preventing respiratory virus transmission for decades; any suspicion of them now likely comes more from the current hyper-politicized, conspiracy saturated climate than from anything else. But the COVID-19 virus is new and acts very differently from other respiratory viruses in so many ways, so what’s to say that masks will be effective for COVID-19?

It is too early in this pandemic to have robust and definite conclusions about which measures helped most and which showed modest or negligible benefits. We know that social distancing helps from evidence in places like Sweden and Norway, and we now seem to be living the results of relaxing our own social distancing measures without other robust mitigation strategies in place. When it comes to masks, we could compare the United States, which is (apparently) very resistant to masks becoming a social norm to places like South Korea where wearing a mask has been the norm since early in the pandemic; but this comparison is complicated by vastly different healthcare systems and populations and by a strong difference in adherence to other mitigation efforts as well, which we Americans have also been consistently defiant of.

Population: 328 Million
Population: 52 Million

I do agree in principal with the approach by one writer to the CDC’s journal, Emerging Infectious Diseases, in comparing Taiwan to Singapore; but again this is not a perfect comparison by any means.

  • Update: It has been pointed out to me that there are now several recently published studies, conducted during the COVID-19 pandemic itself, that have looked at the issue of mask wearing to determine if the benefit is significant. You can find two of them here and here (with thanks to Baylor Epidemiologist Dr. Emily Smith, PhD, who has written an excellent summary of the current evidence for masks). I’m sure many more studies are ongoing. Of course none of these are going to be able to perfectly measure the effectiveness of masking under real life pandemic conditions; if you can imagine a scientific experiment that could, it would probably be unethical and immoral (and logistically impossible), such as taking members of a population and randomizing them to wearing or not wearing masks and then measuring how many become sick from each group. Those types of study designs are entirely off the table, so we analyze epidemiological data; looking at what happened in countries, regions, and cities where masks were adopted early, and what happened in other places after they were adopted later on. It isn’t possible to know how well the mask policies were followed from such data, or to perfectly tease out confounding factors like social distancing measures, the success of contact tracing, and the robustness of testing programs; it wouldn’t be possible to say masks are the most important thing if they are always or nearly always used in conjunction with other mitigation strategies, which is exactly how they should be used. But these studies do conclude that implementing mask policies (and following them!) makes a significant difference in the trajectory of this pandemic, and taken as just one important kind of the multiple kinds of evidence we have looked at, I do think they contribute to a convincing case for wearing masks.

Ultimately, once this turns the corner, we will never be able to say with certainty what the real answer was; whether it was wearing masks that helped the most or the heightened caution in other areas when cases began to climb, whether reopening resulted in a surge here in Texas or if it was our bucking of social distancing all along, whether each of our mitigation measures individually made a difference or not. What we can say for certain is that the American method so far has not been working. By denying the disease’s existence and danger, producing conspiracy theory after conspiracy theory, claiming we beat it prematurely, and fighting tooth and nail against every reasonable recommendation and rule meant to protect ourselves and our neighbors, we have taken a global pandemic and made it largely into an American pandemic, with the highest number of cases and deaths in the world.

There is plenty of evidence that masks are safe, and that they stand a fair chance of helping, especially against asymptomatic and presymptomatic spread. If you are sick, get tested, stay home, and isolate; make sure you get the medical care you need. If you are well and can physically distance yourself from others, then distance yourself from others while finding ways to still care for your community and your own mental and physical health. If you cannot distance because of strong religious or moral convictions or the realities of your job, or due to strong personal preferences, then please wear a mask and wash your hands frequently.

This is just one of the ways we can do better during the rest of this pandemic; myself included.

Dallas Doctor Speaks at Set Texas Free Rally

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.”
  • Populations:
    • 330 million in the US
    • 29 million in the State of Texas
    • 2 million people in Dallas
  • Deaths:
    • 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:

  • US
    • Population 330 million
    • 89,932 Deaths from COVID-19
  • Texas
    • Population 29 million
    • 1,336 Deaths from COVID-19
  • Dallas
    • 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.

We also have a used 2012 Honda Odyssey minivan. Jealous?

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 5:126:30, 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.

Not Candy.

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.

Update 5/22: Click the image to read a study form the Lance published today.

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:

The pharmacist asking for the Diagnosis was wise to do so.

Or maybe it was because of this rule from the Texas State Board of Pharmacy:

If the pharmacist had not asked for a Diagnosis, he would be committing malpractice.

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.