Author Archives: drcharles

The Self-Defeating Logic of Gym Memberships

I belong to a local gym.  I’m supposed to go there to exercise.  I pay $40 a month for the privilege, but I would estimate that I actually get to the gym twice a month.  This failure to find the necessary time to work out is by itself a self-defeating, exercise-discouraging proposition.  By equating exercise with a third-party gymnasium, do we undermine our very notion of healthy activity?  Should not getting to the gym = not exercising?  Here are some ways to correct this fallacy of inherent defeat.

If you conflate healthy physical activity with a time and place that is not readily accessible, you unwittingly place a firewall around succeeding.  For example, I worked until dinnertime last night, had to run home (drive in a car, that is), and take care of domestic duties for the rest of the night.  By the time I might consider going to the gym it was already 11:00 PM.  Therefore yet another day of physical inactivity because there was simply no way to fit in the 1-1.5 hours needed to execute a trip to the local sweat house.

Are we exercising less because of this faulty logic?  Like other activities we outsource, ultimately there is a loss of efficiency and joy.  Look at cooking.  For some people making dinner is just too time consuming.  They rely instead upon take out, half assembled meals, or processed food.  The food infrastructure in the fridge collapses – no garlic, no basic ingredients, rotten milk… so that when a quick meal is desired, it actually takes more time to find an edible assortment of ingredients that could pass as a meal.  Better to cook your own food most of the time, and keep a healthy, steady supply chain coming from the grocery store.

Exercise does not have to entail purchasing a right to machinery, group psychology, and a physical location separate from the rest of your daily life.  As this Wall Street Journal article shows, some boutique gyms are charging upwards of $30 dollars for an individual class, with no coupons or discounts.   Outrageous and expensive.

Here are some ways that you can get the cardiovascular benefits of exercise during the day, without settling in to an unhealthy lifestyle that can’t find the large chunk of time needed for the gym.  Several goods apps and websites exist that demonstrate home exercise routines using no equipment other than your own body.  My favorite is a free site called Darebee, which has countless exercise routines and videos to demonstrate proper techniques.  For a while I was doing these exercise almost once a day, sometimes scattered in between patients, or at night after the manic clock of efficiency can be turned off.  Some of these exercises like the burpees may have contributed to a groin pull I sustained, so remember your age and realistic fitness level!  Just go for a walk once a day, anytime, anyplace.

Taking the stairs, getting up and walking around the house/office at least 2-3 times per hour, and even fidgeting at your desk can help immensely.  One study found measurable benefits to circulation by tapping your toes and moving your feet up and down while marooned at a desk all day.

The gym is also covered in germs.  I heard a recent podcast, can’t recall the source, that described a recent study showing more harmful bacteria on the average free weight than on the average toilet seat!  Always wash your hands at the gym, and long pants seriously recommended.  But I digress…

So in summary, if you are in a busy, time-contrained phase of life, the old habit of equating “getting to the gym” with “getting exercise” is flawed.  It will actually make you unhealthier and more frustrated and defeated.  To maintain that gym membership as the only avenue for working out is a modern fallacy.  Instead, stay active as much as possible during the day, from fidgeting to stretching to walking to running.  If you can make it to the gym, that’s awesome and I must admit that I am jealous.  There are surely a lot of reinforcing psychological benefits to group exercise, as well as having access to better equipment.

On your mark, get set, stand up and move around a little!  Inspiring.

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The Rise of Apps to Monitor Chronic Disease

The Wall Street Journal has an interesting article about the increasing sophistication of personal apps on your electronic device to help monitor and treat conditions such as diabetes, COPD, CHF, and hypertension.  Although not a new idea by any means, the concept of self-monitoring with apps is getting more sophisticated.  Instead of simply entering data and tracking numbers, many of these apps are fusing with body sensors, directing linking with health care systems and doctors, and applying algorithms to optimize compliance with medications, and to produce early warning alerts prompting interventions that might ultimately keep people out of the hospital.

The WSJ cites developments in several disease models:

Diabetes – this condition exists along a continuum.  Type 1 diabetes requiring extremely vigilant monitoring and anticipation of insulin needs multiple times a day; whereas a mild case of adult Type 2 diabetes may require attention to lifestyle and diet alone, with monitoring of HBA1c levels every three to six months.   Apps are similarly available along a continuum of lifestyle coaching, from vital signs and activity monitoring, to intensive blood sugar monitoring with feedback to help determine insulin requirements.

Although the Wall Street Journal reports on several studies showing improved patient outcomes, it would be interesting to see if such intense monitoring of activities and diet leads to a reduction in quality of life.  Some people thrive on having their fitbit measure their daily activity.  But others feel such monitoring is intrusive, a burden, and down right depressing.  Other studies have shown the opposite, namely that monitoring blood glucose levels may improve mood scores, and add a sense of control.

Heart Disease : The WSJ reviews some programs such as one for patients undergoing cardiac rehabilitation after suffering a heart attack.  Once again, the results of vital signs, activity, and lifestyle monitoring seem positive in terms of better outcomes and functional status after a typical period of rehab.  The cardiologist quoted does bring up a sensible goal, that such intensive monitoring be used during an initial, educational and highly structured period to get people on the right track.  But then as their health improves and the conditions are better understood and accepted, the patients graduate to less structured self care and self-monitoring.

All of this does bring up important questions:

At what point does all this monitoring and surveillance become intrusive?

In the social media era, we have had a serious erosion of privacy and personal boundaries.  How much self awareness and self measurement and reporting do we tolerate before wanting to rip everything off and run wildly through open fields?

The “pill for every problem” assumption that guides the medical/pharma complex of today’s healthcare system may soon be joined by the “app for every problem.”  Is this more empowering than burdensome?   Does is lead to uniform dependence on one size fits all treatment approaches, or does it liberate more patients from dependence on doctors, pills, and a vast amount of knowledge they simply have to trust their doctors are relying upon.

With the anticipated ubiquitousness of sensors, penetrating, riding, and floating around the human body in the coming decades, what will the integrity of the human body amount to?  Are we simply phenomena like the weather to be tracked, predicted, and engineered?  Will the increasing alarms and whistles signaling problems and suboptimal statuses soon fill our minds like a the beeping of an open refrigerator door?

Answers to such questions will be different for each person, and I suspect that generational lines will define much of the degree of acceptance of health care apps.  With the future of mankind fusing with inorganic technologies, it seems the infrastructure for monitoring the cyborg machines future humans may become is already developing with these support tools for the still-organic, early 21st century human.

The companies developing such apps, linking them with healthcare systems and populations, figure to rise in the ranks of prominent corporations featured in the Wall Street Journal as well, as the one segment of our future economic model that seems sure to generate productivity of some sort will be tending to human health.

Until its all just robots.

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medical work horses

How To Be More Efficient As A Primary Care Doctor

As an overextended physician in my 40’s, with a family life and a daily sense of exhaustion, I have given up the quixotic dream of helping to change healthcare in this country. I’m just trying to survive each day, along with my patients, and to be an efficient and helpful primary care doctor.

If you too have accepted that our healthcare system is a bloated, unfixable, disappointing mess, and that you are just a squirrel trying to get a nut each day, then read on for small tips on how to survive, nay thrive, within the sad drama that has become the modern office visit.

Resolve that someday, when perhaps you are better rested, better informed, and the industrial-capitalist-insurance-forprofit model has eaten itself alive, perhaps then you will return to your passionate dreams about how to be a better doctor and craft a better medical world. In the meantime, here’s an atomic bomb shelter model to survive.

1. See patients in one room
I used to carry a laptop from room to room, fumbling around and drifting from place to place to see patients. Stop that. Set up shop in one room, and plan on being there for most of the day. Get a comfortable chair. A green plant. A mug of coffee and a water bottle. One room facilitates the rest of this list as you will see. Patients can be brought back and their visits begun in an adjacent room. When you are ready for them, leave your room and ask them to kindly join you next door where you’ve been preparing for their visit. Unless they are extremely old or frail, they will get used to the shtick, and come to expect it.

2. Take 1-5 minutes to review each chart before starting the visit
I used to feel so bad about running late that after finishing with one patient, I would burst into the next room, as if punching a time card, and apologize to the patient, barely knowing whom I was seeing next. Forget that. It doesn’t serve you or the patient to be unprepared for the visit. You will make mistakes, be unfocused, and look like you don’t remember them.

Instead, sit in your little home base with the door closed. Review the last visit or two. Jot down some quick reminders on an actual piece of paper. Among the 15 complaints from last visit, which ones still need attention? I write down chief complaints and quick to do lists. (Last visit – Chest pain, ?stress test done. Elevated alk phos. Bone scan ok. ?paget’s. See rheum. DM2. HTN. Colonoscopy scheduled? Dysphagia, needs EGD. Etc)

Review imaging tests. Jot down loose ends. Review specialist letters’ conclusions. Review recent labs.

Scan vital signs. Did they lose 20 pounds since last visit, unintentionally? Is the BP 180/100? Bad to miss that.

3. Set up the assessment and plan
Yes, do this before the visit. I know you haven’t even seen the patient yet, but unless she is here for a quick same day visit, she’s going to have her own agenda and priorities as soon as you open the door. If you don’t crystalize your own agenda before you are juggling hers, the visit is going to be even more of a struggle.

List 5-15 chronic or recent problems on the chart’s assessment and plan before even seeing the patient. If there are major tasks you know the patient needs, or has failed to complete, order them before seeing the patient. Chest pain, didn’t get stress test, you’ve already ordered it. You can always delete it.

Once the visit has begun, you can add new complaints and diagnoses. Sometimes the visit can become unruly, and finishing with a problem list 10-20 issues deep is exhausting. But 99214’s and 99215’s result, diligent care is achieved, and everyone is happy-ish.

4. Small talk is good, for a small time
This hurts the most. I love knowing my patients as human beings, appreciating their stories, legends, quirks, bravery, and fears. But this is survival mode, and if you are in a saturated situation with kids to pick up by 6 PM at school after-care, then you must stay on point after a brief detour into humanism.

This really sucks.

5. Let the patient’s agenda come first
You may or may not see the patient holding a tangible list of problems in hand, but what you don’t want to do is take over from the beginning, force your way through your pre-planned list of 5-15 items, and then find out they have 6 more. “I know you are here for a check up today, and I have a lot of questions to review with you from recent visits, but I want to give you the floor first. How are you? What can we help with today?” It sounds like family medicine softness. Kind of deadly. But it is actually eastern Zen philosophy combined with German engineering – letting the visit pass through you without resisting its true motivations, yet holding onto an invisible scaffolding beneath.

Once you’ve handled the patient’s biggest concerns, your preplanned list may already overlap with theirs, making the additional dump of your diligent reminders easier. Don’t drag this part out. You’ve already done the work from prior visits. Lung nodule, due for CT Chest, reminder and script given.

6. Demand enough time
Modern primary care visits cannot be reasonably accomplished in less than 20 minutes. Demand 20 minute visits for chronic care, and 30-40 for the most complex patients, hospital follow ups, new patients, and most “preventative physicals” which end up being chronic disease management with USPTF essentials added in. 15 minutes is disrespecting you and the patient, and making money for someone else anyway. Plus, with better care 99213’s are rare, so it evens out or you come ahead in terms of RVU’s and that stuff.

7. Smile, breathe, laugh if you can
It really helps. But don’t force it. A smiling or laughing doctor at the wrong time is creepy and unnerving.

When rechecking a blood pressure, walk the nervous patient through some calming, deep breaths, and while telling them to relax their muscles, you do the same. No laughing at this time.

8. At the end of the visit, give a narrative outline
Sometimes patients won’t let you talk as much as you need to. They are excited, nervous, or just talkative. You have to wrap this up in a tidy manner for you and them. “So I understand what you’re telling me. I’m going to tell you my impressions about what is going on, then review some diagnostic tests we may or may not want to do to figure this out, and then we’ll talk about treatment options.” That way they know to give you some space to help them. “After that, please ask any questions you have, and then we’ll run through a quick summary of your old issues with some reminders.”

Bring more structure to the visit as it progresses. Hopefully, it is satisfying for you and the patient. Making order out of chaos is what humans do, even if the laws of thermodynamics still prove everything we do ultimately creates more disorder. Alas…

9. Get up and escort patient out at the end of the visit
This is good manners. It is also a ceremonial display that this dramatic interaction has reached its natural conclusion. It stretches your legs, helps your back, and alleviates pressure on your hemorrhoids. Just kidding. Maybe not.

10. Return to your room, close the door
With peace and quiet, finish your note, organize your thoughts into coherent, thoughtful, narrative documentation. I insist on speech-to-text dictation (Dragon medical dictation software). I refuse to click on boxes or try to cram the patient’s complex story, overlapping ideas, and fluid assessment and plan into templates provided by most electronic medical records. It’s not human, and it’s bad. Enough said.

If I’m running more than 30 minutes late, I will stop finishing each note. Instead I will then move on to the next patient’s chart and start the whole pre-gaming process all over again. Leaving the full documentation of the visit for the end of the day, or “lunchbreak” whatever that is, is a total bummer. But it happens.

In between patients, take a deep breath or 5. Close and rub your eyes. Do some tai chi poses, or practice a minute of mindfulness stuff. It really helps, and maybe your first heart attack will delayed.

11. Noble sacrifices will be made
This part is optional, depending on how badly you need to get out on time and pick up your kids, or walk your dog. Consider sacrificing small talk with colleagues. Eat your lunch in that bunker of a room while reviewing the 25 phone calls that have come in for you while you were seeing patients. Put on some music. Stretch. This is a sad departure from those you work with. Optional.

12. Delegate
You can’t do it all. Don’t feel bad. Your mission is to be the doctor. Medical assistants and front desk personnel should be there to support the whole enterprise.

Good luck. Hopefully this will make you a more efficient, more diligent, better doctor within the horrible confines of a typical, busy primary care practice. There is no one-size-fits all. But this approach works for me. I bring significantly less work home, and achieve greater productivity than my colleagues.

I’m soldiering on, muddling through, being a workhorse. These are not visionary pointers, and there is little inspiration in them. But until the larger struggle is won against our broken healthcare system, some of us choose to survive within the system, while others set up systems of care that are off the grid with concierge practices, ideal micro practices, or some other funky model for cash.

It also helps to have a photo depicting a rustic, mossy cabin in the woods posted somewhere.

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how read eyeglass prescription

How To Read a Prescription for Glasses (It’s Easy!)

I get asked how to read prescriptions all the time, including those for glasses. Reading a prescription for eyeglasses from your optometrist is simple, here’s how: (short video)

How to Read a Prescription for Eyeglasses / Common Abbreviations

Ordering prescription glasses online from somewhere like EyeBuyDirect or glasses.com? Be sure you know how to read your prescription!

  • OD = Right Eye (R)
  • OS = Left Eye (L)
  • SPH = “Sphere” or strength of your lens. A “+” positive number means you’re far-sighted while a “” negative number means you’re near-sighted
  • CYL & Axis will be filled in if you have astigmatism. That means your eye is not shaped spherical, but more like a football shape. The Axis is the angle of your astigmatism
  • ADD = Additional strength in your lenses like bifocal, progressive, etc.

Other EyeGlass Prescription Terms:

*PRISM = The prismatic power used to correct vision displacement. (When your eyes don’t align correctly)

*BASE = The way the base of the prism is facing: BU, BD, BI, BO

Pupillary Distance “PD” is the distance from one pupil to the other. PD is needed to order glasses online, but you can measure your own.

*Check out our coupons for EyeBuyDirect to save up to 50% on eyeglasses!  


More coupons: Check out today’s coupons for Scrubs & Beyond, or this deal for 50% off a WSJ subscription!

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trans fat restaurants

Banning Trans-Fatty Acids in Restaurants Saves Lives, Improves Mouth-Feel

Good news for supporters of trans-fatty acid bans: in New York State counties that implemented restrictions on their use in restaurants and eateries, there were significantly fewer admissions to local hospitals for heart attacks and cardiovascular events.

Specifically, researchers found a 6.2% decline in admission for hearts attacks and strokes combined, and an even greater drop of 7.8% for heart attacks alone. Both reductions were statistically significant.

Evidence has accumulated over the years that consuming trans-fatty acids is associated with increased risk of heart disease, stroke, and diabetes. The FDA plans to restrict the use of trans fats in foods nationwide in 2018, but some localities in New York State went ahead and banned TFA’s in restaurants and eateries starting between 2007-2011.

Processed foods, manufactured for long shelf lives, profit, and the creepy notion of “good mouth-feel,” have long been the biggest culprits using TFA’s.

Look for and avoid ingredients like “partially hydrogenated oil” found in many baked goods, cakes, piecrusts, crackers, cookies, biscuits, breakfast sandwiches, margarine, microwave popcorn, cream-filled candies, doughnuts, fried fast foods, and frozen pizza.

Unfortunately manufacturers are currently allowed to list trans fat content as 0 grams if the actual content is below 0.5 grams – kind of like rounding down, except that those small amounts can add up.

A legacy of the Obama administration will go into effect in 2018, when the complete phase-out of trans fatty acids in American foods is scheduled to be completed.  This happened despite intense lobbying by some companies and associations representing fast food and junk food interests.

The FDA estimated that up to 20,000 heart attacks and 7,000 premature deaths could be prevented each year with this phase-out, not to mention significant reductions in diabetes and cardiovascular disease prevalence.  Perhaps $140,000,000,000 will be saved in healthcare costs over 20 years.

New York City in 2006 under Mayor Bloomberg, and then California in 2008, pioneered the way with this enlightened TFA-banning legislation, but the early 1990’s Congress and then President H.W. Bush deserve some credit, too.

The original Nutrition Labeling and Education Act of 1990, sponsored by Democratic Rep. Henry Waxman, passed both houses of Congress and was signed into law by the first President Bush (H.W).

Ahhh… those nostalgic days of working together for the common good.  From Wikipedia:

The law gives the Food and Drug Administration (FDA) authority to require nutrition labeling of most foods regulated by the Agency; and to require that all nutrient content claims (for example, ‘high fiber’, ‘low fat’, etc.) and health claims meet FDA regulations.[2] The act did not require restaurants to comply with the same standards.

The regulations became effective for health claims, ingredient declarations, and percent juice labeling on May 8, 1993 (but percent juice labeling was exempted until May 8, 1994).[2]

Effective Jan. 1, 2006, the Nutrition Facts Labels on packaged food products are required by the FDA to list how many grams of trans fatty acid (trans fat) are contained within one serving of the product.[1]

So it is even more remarkable that a significant drop in heart attacks was seen with these more recent bans in New York, which really targeted the restaurant and eatery loopholes. Fast food and processed food companies had already decreased their use of TFA’s nationwide by some 85% over the past decades, as mounting evidence of harms and impending class action lawsuits loomed larger, and mandatory labeling of trans-fat content in foods increasingly drove educated consumers away from the products sitting on the shelves and lurking in the fryers.  Nationwide there has been a trend towards lower cardiovascular disease prevalence, but this is multifactorial.

The deep fried Twinkie as we know it will recede into the annals of history, conjured only by roving bands of post-apocalyptic freedom fighters raiding pre-WW3 bomb shelter pantries to find the archaic ingredients.

Humans will no longer be seduced by the Frankenstein mouth-feel of partially hydrogenated oils, which honestly, always tasted malicious somehow anyway.

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refined foods

The Inherent Badness of Refinement

sugar refiningI had an interesting conversation with a psychologist friend of mine who specializes in treating sexual addictions. She did not tell me anything interesting in terms of specific cases, practices, or titillating bedroom details, but rather piqued my awareness of the brave new world of dating and casual sex as facilitated by apps like Tinder.

I felt old and naïve as I learned that with a few swipes of the hand on an iPhone, people seeking a casual sexual partner in real time are able to search through profiles of other people, learn perhaps that this person is currently 100 yards away, trade photos for evaluation, and then basically get in on. For someone with a sexual addiction, this immediate gratification is as volatile and irresistible as one might witness placing a kid in front of a basket of Halloween candy. Which brought us to the corrupting notion of refinement in all things.

Take for example the refinement of carbohydrates and sugar in food. There is perhaps no more logical explanation for obesity and its attendant health problems than the free reign of sugar and starch as commodities, separated and refined from their original source.

Every day I hear the self-defeating arguments from people unable to lose weight as they cannot break a seeming addiction to starchy snacks, chips, bread, juices, soda, ice cream, and the like. The middle aisles of the grocery store, full of processed and refined inputs that have been reassembled into something complex enough to be called food, are really just barren wastelands of destroyed nutritional principles, forgotten cuisines, and corporate brand addiction. Freedom may be found in the simple, unwrapped harvest of the Earth.

Alcohol has also been refined to the point of absurdity. For thousands of years humans found health and pleasure in complex beers, ciders, wines, and other products of fermentation – a process which in some ways unlocked additional nutritional values. But over the past several hundred years the process of distilling has refined alcoholic drinks from the complex brews of the past into the simple, potent, hyper-concentrated alcohols and liquors that are often the source of addiction, accidents, and medical problems.

I personally appreciate gin and a good mixed drink, and I have a hard time preaching about the evils of alcohol, because in moderation even distilled spirits can be enjoyable and “healthy.” But for those with a predisposition to alcoholism, the concept of refinement applied in this realm has been lethal.

Which brings everything back to the conversation I had with my psychologist friend about sex, and the refinement of this realm that seems to be going on now. I am actually quite ignorant about what is actually happening out there, but as I learned more about specific websites, it seems that all the complex gratification of a relationship, or the challenging pursuit of another attractive individual – physically, emotionally, spiritually – is being reduced to a smartphone app that sorts available penises and vaginas.

This is of course just the latest development in a continuum that stretches from Playboy, through explicit internet content, and on past all the various distillations of a basic instinct for pleasure that can be satisfied in increasingly refined, uncomplicated ways. Especially for those with an addiction, this impersonal and freely available world in all its iterations is actually imprisoning.

I think that one way to achieve physical health, emotional wellness, and sexual satisfaction would be to paradoxically and intentionally seek the laborious, unrefined world.

Spend more money and time buying real foods, and cooking them, socially, in our own home kitchens, according to the traditions of a cuisine.

If you drink, seek out thoughtful, complex brews, wines and a few spirits, and revel in the magic of the process that brought this relaxing complexity to your lips, instead of enduring vehicle after vehicle of simple ethyl alcohol poisoning.

And beware of the reductionism and refinement of sex that occurs all around us, from the catalogs that arrive at our doors, to the shows on television, to the apps that would transform and enable our most primal urges. Otherwise we will continue to spoil of one of life’s greatest and most exhilaratingly complex pleasures – the physical expression of earned love.

Refinement is dehumanization.

Fight the Powder.

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specialized facilities africa

We Should Construct Specialized Ebola Facilities in the US. Now.

The US should be ready to build facilities, akin to what the military has been setting up in West Africa – specialized Ebola hospitals with moon suits, free-flowing bleach solutions, and brave healthcare workers who have been properly trained, and will be properly compensated for their risk.

Conventional hospitals have failed to protect at least two healthcare workers from contracting Ebola, despite what sounds like fairly diligent safety precautions. The nurse in Spain, and the nurse in Dallas just diagnosed today, both practiced stringent precautions and wore protective gear. It has been postulated that a single Ebola virus is enough to transmit the infection between close contacts.

And, while the CDC director assumes there was “a breach in protocol” to explain the nurse’s infection, this is not reassuring to any healthcare worker who knows how impossible it is to achieve perfection in the care of sick patients. Doctors, nurses, medical workers – we are not trained, prepared, or equipped to deal with something like Ebola.

And even with buddy systems and moon suits, any human being lacks perfect motor execution when disrobing. And the disrobing protocol in this country does not even include being sprayed/bathed in a disinfection solution prior to disrobing – something done in Africa for years. This is outrageous.

Even with regional Ebola treatments centers, the diagnosis and triage of potential infections will likely continue to be through the conventional health system, as false scares will certainly outnumber true diagnoses. But once a diagnosis is made, that patient needs better care, and workers need better protection than all the reassurances thus provided by the CDC and WHO and hospital protocols.

The four hospitals in the country commonly cited by the news as having high containment units do not have sufficient beds to handle Ebola if it picks up speed and numbers. The death toll among healthcare providers in West Africa is much, much higher than the average population. It would be here, too.

The Ebola epidemic continues to grow exponentially in Africa. Today we have the luxury of hyper-focused contact tracking and supervised quarantines in the United States, but these efforts take considerable resources and attention, and will fall apart if the disease count grows. Such is the terrifying power of exponential math.

It is not a good idea to have Ebola patients in conventional hospitals like Texas Presbyterian. Conventional hospitals are already a nexus point of the worst antibiotic-resistant contagions in the world. We need to enlist the help of groups like Doctors Without Borders that really know how to protect their staff, and we need to start thinking about containing and treating this infection outside the normal hospital box.

Build it, and hope they never come.

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