2. Most healthcare workers received no employer based routine testing for COVID during 2020, despite enough testing capacity in the private sector to offer routine testing to everyone from college athletes to tech employees. Many (not all) Employee Health programs kept their 9-4 hours, did not operationalize a call schedule to answer questions from healthcare workers about exposures/ symptoms/ability to work, and took little interest in facilitating or advocating for the testing we deserved.

3. 1 & 2 are profoundly abnormal institutional responses to danger. What would drive such behavior?

• Incompetence

• Indifference

• The conscious or unconscious decision to prioritize money over safety

4. Say more.

• Incompetence: These threats were understood but the response was bungled because those in charge could not accurately assess and appropriately problem solve.

• Indifference: These threats were understood but they didn’t affect the (often corporate) decision makers, so the drive to correct was absent.

• Economics: Setting boundaries with patients by dismissing them from a practice, turning off messaging, or placing an assault warning in a chart would risk loss of revenue, either from insurance membership or RVUs. Screening healthcare workers for COVID, especially if asymptomatic or their infection could be tied to the workplace, would risk the very quantifiable downside of having to pay for staff time to get tested (yes, whether nurses should get paid for an extra 15 minutes so they could come in early and get tested was debated), staff coverage for furloughed workers, and workman’s compensation claims.

5. Social media is full of people telling healthcare workers how to be well. Our physical safety is a place to start.

This JAMA article (March 2020) formed the basis of policy a lot of us disagreed with during COVID.

My notes, before we do this again, because we likely will:

1. Mitigation may be the right approach for some contagious illnesses once community transmission is verified in *non-healthcare settings*.

2. Mitigation is NEVER the goal for highly contagious diseases in a hospital - containment is the goal. We do not mitigate influenza, tuberculosis, varicella, or measles in the hospital for many reasons including patient susceptibility due underlying diseases, patient density, healthcare worker density, and close contact between healthcare workers and patients.

3. Droplet transmission and airborne transmission exist in a continuum, not as a binary. That continuum (low to high risk of transmission) looks something like rhinovirus -> COVID -> measles.

4. The debate about mode of transmission of novel disease should not distract from the general infection control principle that novel viruses within the hospital setting are handled with maximum precautions until we definitively know to do otherwise.

5. Pre-emptive compromise due to anticipated supply chain or space issues muddies the water and sets up a lack of safety. Ideal state should first be outlined, followed by necessary compromises and their risks. Supply chain transparency is mandatory. Ideal hospital policy state in March of 2020 was not droplet masks.

6. Masking as source control of patients seeking care should never have been up for debate in this or any organization. It is another fundamental infection control principle anyone who works in this space understands.

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You leveraged your position to get an urgent COVID test for yourself in the spring of 2020 (and did the same months later for your child) instead of following the protocol every other patient had to follow. You were scared, with a relentless cough and exertional tachycardia. We took your call. You got better. Why did you skip the line (for testing and medical advice)? Why did you teach your kid to do the same? Why didn’t you combine your personal understanding of this new and devastating illness and your power within our organization to fund the equipment our teams desperately needed?

You laughed at our hospital during a regional command center call. Our numbers peaked early in March (weeks before New York) because of our specific geographic location and patient population. We were scared and exhausted. It wasn’t funny.

Remember calling us daily from abroad, when your dad was dying of COVID, and we told you what to do?

Why did you text us about arranging a test for someone connected to the president of the organization instead of giving that person the very language you crafted for patient communications about how to access testing?

You asked us early that summer to use our precious local expedited COVID tests, the ones that resulted within hours and were used to enroll people in the Remdesivir and convalescent plasma trials, for politically important and asymptomatic outpatients. Your reasoning? 6 members of the a hospital association needed to attend an important in-person meeting. We were telling people over Facetime their loved ones were dead. That meeting did not need to be in-person.

We spoke to your brother’s doctor in another part of the country and shared our clinical experience. We can’t remember when this was, so we put it in this part of the story. We thought we were really good friends and so accessing those memories is still particularly painful.

Remember the promises you made to the large employer groups you sold your insurance product to about testing availability? We attended those meetings, by the way, with teachers’ groups and transit workers whose testing needs we couldn’t meet. They deserved more than we provided. You were not happy that we gave them your phone number and email address, and reminded us that you needed to stay in the background.

Later that summer, a laboratory worker spent hours looking for a sample amongst the thousands in queue at our lab and was instructed to run it immediately, which meant ahead of the symptomatic, sick, and hospitalized patients. The sample had been collected from the child of a well-connected politician. The child was fine, but had been exposed to COVID, which at that time was a lower priority for testing. You were on a trip with your kid while talking to us and making these special arrangements. Same question about your kid and what they learned from watching you prioritize lives.

Why were you so quick to shut down our COVID equity group? We advocated for concrete things like extra time for visits when there was a monolingual non-English speaker paired with a language discordant healthcare worker. We appreciated everything you did to make language and culturally appropriate educational materials and we wanted to go further. The explanation that there were already people working in that space didn’t make a lot of sense to us, since those people welcomed our presence. Are there ever too many people working in the equity space?

You took leadership of the COVID Clinical Library away from us and transferred it to a different human. Yes, that person did receive a text discouraging him from accepting that role - it is unethical and frankly embarrassing to take something 3 women built and put your name on it. We understand you didn’t like that, and we see now that the groundwork for our demise within the organization was actually set several years before that event, when we questioned the legitimacy of the different human’s predecessor, who obtained his leadership appointment with no application process or vetting. It seemed like he got the job, and 50% administrative time, because he was your friend and mentor. That human’s legacy (and yours)? Leading a dangerous and bewildering effort to prevent us from using N95 masks for the routine care of COVID patients while demonizing and devaluing colleagues’ (including unionized non-physician healthcare workers) and requests for safe workplace conditions (you favored terms like ill-informed and unreasonable). You do not have to take our word for it, you can read the informal yet deeply informative survey the ER doctors did about your leadership. A reminder that we were copied on all the supply emails and the texts about not sharing that supply chain data with the front-line, so that argument doesn’t land.

Why did we have no employer-based healthcare worker testing for all of 2020, including during the winter when the community burden of disease was astronomical? Not the testing we wrote into the patient testing guidelines, which stayed concordant with public health recommendations, and allowed for employees who HAPPENED to have our organization’s insurance to get tested as PATIENTS. This question is about the employer-based testing mandate for healthcare workers in CDPH AFL 20-88 (we can still remember that without Googling it) that said healthcare workers should be routinely tested for COVID, regardless of symptoms. We remember the command center call in November of 2020 when the CDPH AFL was discussed. You spoke about how you were going to take this up with the governor before implementing it. Why would you not want to test us? Our theory is that asymptomatic healthcare workers with COVID couldn’t work and you wanted us to work, despite the danger it posed to our patients. That aligns with the previous organizational deviation from public health recommendations about testing and work restricting those of us who were exposed to COVID in the community, which you sold as necessary because we were in “surge status” something you never defined and which worked out to mean we were always in surge status. Around this time, I think several of you reported us to HR because we kept bringing these safety issues up. By this time local animal shelters had figured out how to regularly test their employees for COVID – as such we are still not interested in supply chain arguments, internal lab capacity, or being pit against our unionized colleagues. There were external vendors who could have met the need.

Why didn’t you turn off testing for pre-leisure travel in December of 2020 when our hospitals were overwhelmed and we needed that testing capacity for sick inpatients?

Do you remember getting a call from a sports organization asking for monoclonal antibodies for healthy people associated with a sports franchise when we were using them for transplant patients? Did you say yes or no to that request? We were told you said yes, and we have several messages that support that assertion, but the letter your legal team crafted didn’t substantiate our concerns. We are glad you didn’t say yes, because that would have been a gross misallocation of resources.

Why were you so upset when we went to the national organization with our request to make N95 masks standard for COVID care? This was well into 2021, when every other large healthcare organization had already done this (you can reference the hundreds of power point slides we sent many in leadership reviewing the discrepancies between our organization’s COVID testing and PPE guidance and everyone else’s approach). Why did you have a seat at that table anyway? Usually, the person in our position held that seat.

Why did you come to our office after we disagreed with you, tell us you were a Wolverine and pound for pound the most ferocious mammal alive, and then stick out your hands like you wanted to strangle us? Why did you do that three times?

Why did you trust us enough to call us about your daughter and your mom over the years and then turn around and oversee the initial HR investigation against us and also the second one, which was initiated unbeknownst to us and 2 weeks after we filed a formal complaint about the organization’s COVID response to the Board of Directors? Are you aware that retaliation and secret investigations are frowned upon? What made you think it was appropriate to send us to a 3 day Medical Board of California Anger Management program with a 3 month follow up program? Were you trying to humiliate us or make us be quiet? Yes, we were angry. You should have been too. Note: We didn’t expect blind loyalty, but we did hope for fairness.

You should have been angry and devastated at the shambles our community was in and the role our physician-led healthcare organization had in destroying trust and failing to meet its commitments. Instead, you used us and then you turned on us. Were you always this way? Did you become this way because you love the power? Do you need this administrative job because it pays well? Or do you need it because you cannot go back and do the front-line work in the system you created? Or do you believe like we did, that you can work within the system and create change?

Did you get your job because of loyalty or because of skill and expertise? If you got it because of loyalty, and the winds shift, we hope those who take power are kinder to you than you were to us. We hope the little people in your life respect you.

Mutually recognized competence is a love language that we should talk about more. That feeling, when you are sharing a cognitive space with someone, and you silently realize how exceptional they are. You reach an immediate non-verbal understanding. And over time, you understand how much you’ve leveled up by absorbing their way of being in the world.

This article is the 3rd I’ve gotten to co-author with . A different subject than our other two, but rooted in a continued shared curiosity that I feel lucky to be a part of -

Link here: https://www.medpagetoday.com/opinion/calamities/122078

And the full text here:

About 8 months ago, a bug enthusiast on the outskirts of Reykjavik, Iceland wandered into his yard at dusk to survey his latest wine roping haul -- a hobby in which fabric soaked in sweet wine is used to lure insects. Suddenly, the evening took an unexpected turnopens in a new tab or window. As Björn Hjaltason later noted on a Facebook chat, “I caught sight of a strange fly...I immediately suspected what was going on.” He snapped a few photos and sent them to an entomologist, who confirmed his hunch.

Until recently, Iceland was one of the last areas in the world without mosquitoes. Hjaltason had just caught the country’s first wild mosquito.

Humanity’s Deadliest Predator

As two physicians in emergency medicine and infectious diseases, we viewed this development with curiosity but not surprise. As long as there have been humans, there have been mosquitoes. And as long as there have been mosquitoes, there has been mosquito-borne illness. Mosquitoes have altered human genetics (think sickle cell diseaseopens in a new tab or window), ended warsopens in a new tab or window (the American Revolution) and inspired beveragesopens in a new tab or window (the gin and tonic). And they’ve killed more humans than any other species on earth: up to half of the 108 billion humans who ever lived died from mosquito-borne illnessopens in a new tab or window. Today, 1 million humans dieopens in a new tab or window annually from dengue, West Nile, Zika, chikungunya, yellow fever, and of course, malaria.

And if there’s an organism out there that’s benefitting from climate change, globalization, and urbanization, the mosquito is it. Changing precipitation patterns and warming temperatures increasingly permit cold-blooded mosquitoes to survive at higher latitudes and altitudesopens in a new tab or window. The speed of today’s air travel means mosquitoes can cross all sorts of international borders: in 2016, for instance, six yellow fever mosquitoesopens in a new tab or window were captured at Schiphol Airport in the Netherlands. Add to that urbanization (which means more standing water) and deforestation (fewer mosquito predators), and it’s not difficult to understand why mosquitoes are on the march.

A great example is the Aedes mosquito, which is so exquisitely adaptedopens in a new tab or window to living with and infecting humans that it’s been referred to as “domesticatedopens in a new tab or window“ (It adores human blood, feeds primarily during the day, and can lay 200 eggs in a Coke bottle cap). Aedes’ global distribution has explodedopens in a new tab or window in the past few decades: it’s endemic and thriving in much of the southern U.S.opens in a new tab or window, well-established in southern Europeopens in a new tab or window, and gaining a solid foothold in southern Canadaopens in a new tab or window and Patagoniaopens in a new tab or window.

Brave New World

So what happens when mosquitoes move poleward, where residents are largely immunologically naiveopens in a new tab or window to the infections they carry? Predictably, mosquito-borne diseases emerge or re-emerge in non-endemic areas.

Take dengue, for instance, which is transmitted by the hardy and rapacious Aedes. In 2024, the world saw the highest numberopens in a new tab or window of dengue infections and deaths ever. That same year, Puerto Rico declaredopens in a new tab or window dengue a public health emergency amidst elevated case counts, while Florida and Texas reported 92 autochthonous casesopens in a new tab or window. Similarly, in Californiaopens in a new tab or window, dengue casesopens in a new tab or window jumped from 130 in 2022 (all imported) to 720opens in a new tab or window (with 18 locally acquired) just 2 years later.

And then there’s malaria. Malaria was eliminated in the U.S.opens in a new tab or window in the 1950s but its vector, the Anopheles mosquito, remains endemic. In 2023, a convergence of post-pandemic travel (and more imported malaria) with the fifth hottest summer on record resulted in the U.S.’s first locally acquired malariaopens in a new tab or window in two decades.

Meanwhile, mosquito-borne illness already endemic in the global North is also on the rise. West Nile Virus increased in both incidenceopens in a new tab or windowand severityopens in a new tab or window last year, as did eastern equine encephalitisopens in a new tab or window, and the U.S. recently confirmed its first locally acquired case of chikungunyaopens in a new tab or window in a decade.

Stung to the Quick

Now, we’re rapidly approaching the height of mosquito seasonopens in a new tab or window. For clinicians, the changing epidemiology of mosquito-borne illness presents a growing conundrum. Physicians are classically taught to ask about international travel, but this may no longer be the right question.

When infectious disease risk is influenced as much by ecologic as national borders, we might be better off asking, “Where in the southeast U.S. were you?”

Or, “Did you visit California?”

Other factors such as housing density, a history of outdoor labor, and exposure to animals also assume increasing relevance in a warming climate.

When parts of the U.S. share the same epidemiology as the global South, a patient’s differential diagnosis expands tremendously. This means reimagining disease risk to consider previously rare conditions -- the “zebrasopens in a new tab or window“ -- with newfound seriousness. A patient with hemorrhage, liver inflammation, and no travel history, for instance, might harbor a mosquito-borne illness rather than simply being a slam-dunk cirrhosis or leukemia.

At issue is the fact that we don’t know what we don’t know. Physicians of the global North generally lack experience treating these infections that were once far-flung. When one U.S. physician developed fevers, bone-breaking myalgias, and a weird rash, all the physicians involved in her care (including the patient) were first perplexed and then blindsided by her textbook case of dengueopens in a new tab or window. Similarly, among locally acquired dengue casesopens in a new tab or window in Los Angeles in 2024, the median time from symptom onset to dengue testing was 9 days, reflecting clinicians’ overall low index of suspicion for the disease.

Our health systems are also under-prepared. When a patient presented with malariaopens in a new tab or window to a facility in New Orleans, clinicians found that it took 48 hours to confirm the diagnosis and 3 days to initiate the recommended treatment, due to the fact that the first-line medication had to be shipped from another facility. These types of knowledge and systems gaps are especially worrisome as they present a risk to both the individual and the community -- infected patients can and have served as a nidus for broader spread.

The arrival of humanity’s apex predator in Iceland is a warning and a reminder for all of us. Humans have long been at battle with the mosquito, and the insect has often had the upper hand. Its legacy is not yet finished. It’s time to prepare our clinicians and our health systems for the return of the “ancient” diseases mosquitoes carry -- or face the consequences.

This perspective is the authors’ alone and does not necessarily reflect that of any institutions or companies with which they are affiliated.

Dear Charu, I have been meaning to write to you for some time. The article I read in the New York Times about Columbia made me think of you, because there are so many parallels. Then I got your essay on the same topic.

In February of 2022, I sent a 6 page letter to my organization’s Board of Directors with carefully considered concerns about patient safety, healthcare worker safety, and equity. I was deeply aware of the complexities of being a leader, having served in many such roles during my 13 years at the organization. I wanted to be fair, so I spent a year putting together 1000 power point slides and creating a spreadsheet with names, dates, email addresses, and phone numbers of people who could be interviewed to supply information independently.

At my request, external investigators were hired. The two main investigators were from a large, global law firm. They were both attorneys. I found this very reassuring. I prepared extensively for our multi-day interview. I wore a suit. I had printed timelines and prepared my computer screen to be shared with carefully labeled folders organized by topic and date.

The news is full of stories about wrongdoing in healthcare. Many of us applaud when an investigation is commissioned. And – too few of us ask if healthcare systems can honestly investigate themselves, whether external investigators function independently or at the behest of the institutions that hire them, and how often Boards of Directors hide behind a narrow definition of fiduciary responsibility that doesn’t align with the values of healing, safety, and transparency.

1. Last month, in March 2026, Mount Sinai Health System’s Board of Trustees announced the formation of an ad hoc committee to review the organization’s ties to convicted sex offender Jeffrey Epstein.

1a. Who is on the Board of Trustees of Mount Sinai Health System? There isn’t a comprehensive board membership list available on their official website, though a gala directory does list its members. There are over 50 people on the Board, including several judges and multiple physicians.

1b. Who is the Chairperson of the Mount Sinai Board? John B. Hess is the current Chair. He was recently elected to his role as Chair, and has served on the Board since 1988.

1c. Who led the Mount Sinai Board before Mr. Hess? In 2019, Peter W. May stepped down as the Chairperson after leading the Board for 17 years, and Co-Chairs Richard A. Friedman (a Trustee since 2001) and James S. Tisch (a Trustee since 1988) were appointed.

1d. All four Chairmen of the Mount Sinai Health System Board of Trustees were on the Board in 2008, when Jeffrey Epstein pleaded guilty to sex crimes with a child? Yes.

1e. After 2008, did Mount Sinai sever its relationship with predator Jeffrey Epstein? No.

2. What evidence is there that Mount Sinai leadership, including its CEO and multiple Trustees, interacted with Epstein after his 2008 child prostitution guilty plea?

2a. Politico has reported on the elite access Epstein had to plastic surgeons, cardiologists, and other physicians at Mt. Sinai through at least 2016 (8 years after pleading guilty to child prostitution).

2b. Epstein received multiple emails from former Board Chair Peter May inviting him to exclusive events at which board members and Dr. Kenneth Davis (a physician and former health system CEO) were in attendance through 2017 (9 years after pleading guilty to child prostitution).

2c. Dr. Eva Dubin, a physician who also sits on the Mt. Sinai Board of Directors, maintained ties to Epstein well after 2008. In 2009, Epstein attended a fundraising event for her new breast center, which is housed within the Tisch Cancer Institute (founded by a donation from the Trustee and former Board Co-Chair James S. Tisch). The breast center was funded by her husband and Epstein file frequent flier Glenn Dubin (also on the Board) and Epstein himself.

2d. Brad Karp (former Paul Weiss Chair whose moral framework allowed him to capitulate to Trump), appears to still sit on the Mt. Sinai Board despite calls for him to step away after extensive correspondence with Epstein came to light.

3. On July 6, 2019, 11 years after he pleaded guilty to child prostitution in Florida, Epstein was arrested in New York. On August 10, 2019, he was found dead in his cell. After Epstein’s well publicized arrest, Mt. Sinai committed to returning the money Epstein had donated.

3a. On July 24, 2019, the Miami Herald reported that Epstein had donated $15,000 to Mt. Sinai.

3b. On August 24, 2019, 2 weeks after Epstein’s death, Mt. Sinai released a statement indicating it would redirect the money, “contributing a sum equal to the donations we received from Mr. Epstein and his foundation to a charity focused on preventing human trafficking and sexual exploitation, as well as providing financial support for the work of our Sexual Assault and Violence Intervention Program (SAVI)”.

3c. Politico reports that the sum Epstein donated to Mt. Sinai exceeded $250,000. They got to this sum by combing through the Epstein files because Mt. Sinai was unwilling to provide that information directly to journalists.

3d. Mt. Sinai hasn’t updated their 2019 statement to reflect how much they have committed to exploitation prevention efforts. There have been no public statements by the Board chair or any of the prominent trustees about donations. I suggest anyone who has the time take a look at the SAVI website and social media page and decide for themselves if it appears to be a well funded sexual violence intervention program.

4. Will this ad hoc committee of the Mt. Sinai Board of Trustees get this investigation right?

4a. Thus far, the Board leadership has demonstrated tolerance for association with Jeffrey Epstein. It has issued no public statements about Board members Glenn Dubin, Eva Dubin, or Brad Karp. It has made no statements about Epstein being invited to exclusive Sinai events.

4b. Many Board members’ individual reputations and financial legacies are tied deeply to the organization’s reputation. The board has yet to issue any meaningful public statements about financial or other repair.

4c. The Board has yet to name the members of the ad hoc committee for investigation, whether the committee will report to an external and independent governing body, and what assurances we will have that the scope and power of the investigators will be greater than the self-interest of the organization.

In 2022, I indexed heavily on my Board being comprised of physicians. I was sure that they would get it right and that I could believe their findings. I didn’t realize that my own Board of Directors had an unusual structure, in that all of its members were internal to the organization. These physician board members were supposed to hold the CEO accountable, while also having their salaries and medical center budgets set by that CEO. I didn’t know that the attorneys hired to investigate my claims were known for their defense of employers and that my letter, meant to put us all on the same team so we could figure out how to get it right next time, was not received that way.

In August of 2022, I received a summary of the investigators’ report and was told that none of my concerns had been substantiated. I learned that I too had been investigated over the previous 6 months, and received a list of disciplinary actions I would face. A letter (listing the findings and disciplinary actions) on behalf of my Board and signed by the Chair was handed to me and mailed to my home. Part 4 of this series will talk about State Medical Boards and their role in disciplining physicians.

As I’ve said before, I am still not sure where the truth lies and how I could have gotten my understanding of things so wrong. Can the power of a few individuals within any healthcare system disproportionately influence outcomes? Can any large medical or healthcare entity, including Mt. Sinai, free itself from the tangled web of money and power and carry out an investigation with the necessary scope and independence to create justice and very necessary change?

I listened to Exposed (the podcast about Columbia University’s 30 year coverup of disgraced gynecologist Robert Hadden’s behavior) with horror and sadness. But not with disbelief. Working in infection control and patient safety/quality, reporting through risk management structures, and seeing the power given to those who manage reputational and financial risk within healthcare organizations made little about this series a surprise.

1. Deprioritizing (Individual and Collective) Patient Safety Over (Institutional) Risk Management.

1a. On May 23, 2022, the Adult Survivors of Sexual Abuse Act passed in New York state, allowing an 18 month window for sexual assault survivors whose statute of limitations had expired to take legal action against their abusers. Two of the act’s strongest proponents were women who had been assaulted by (Dr.) Robert Haden, the Columbia University gynecologist who sexually abused hundreds of patients between 1993 and 2012.

1b. Confusingly to some (and not surprisingly to others), Columbia University refused to notify Robert Hadden’s patients of his conviction, the extended statute of limitations (allowing legal action until November 23, 2023), and their right to sue under this extended statute of limitations.

1c. Who could survivors sue under this new legislation? They could sue their abuser - Robert Hadden. Importantly, the law also allowed survivors to sue the institutions that protected the abusers.

2. Is it difficult to identify and notify patients who may have been affected by a patient safety event? No.

2a. When a large scale patient safety event occurs, for example a measles exposure or an equipment reprocessing failure (resulting in the use of non-sterile equipment during a procedure), the first step is to determine an “exposure window” and generate a list of potentially affected patients. We call this a “line list”. Anyone who works in patient safety or risk management knows how to do this.

2b. The line list can be pulled from any one of many systems - scheduling software, registration software, billing records, or insurance records. It isn’t hard or complicated. For a measles exposure in an emergency room for example, this list can be generated within hours. During the last reprocessing failure investigation I worked, the list was available in under a day.

2c. Under ideal circumstances, patients are notified, the risk is explained, and appropriate mitigation steps are taken. Continuing the measles example, post-exposure prophylaxis can be offered, with priority given to the most vulnerable patients - those under 12 months of age, pregnant non-immune people, and the severely immunocompromised. For equipment reprocessing failures, patients can be offered testing for HIV and viral hepatitis.

2d. From the perspective of a healthcare organization, the patient notification process may be labor intensive and expensive, but it should not be ethically complex. That doesn’t mean there isn’t resistance to patient notification – those in charge of reputational and financial risk can and do put up barriers. It was not a leap for me to see how a sexual predator was permitted to see patients for almost two decades at Columbia University and how the organization abdicated its responsibility to notify patients.

3. Did Columbia University take the necessary procedural and moral steps to notify survivors of Robert Hadden’s conviction and their right to take legal action? No.

3a. Between March 23, 2022 (the date the Adult Survivors Act passed) and September 2023 (2 months before the extended statute would run out), there were no patient notifications sent.

3b. The university did issue a performative apology in September of 2023 in response to public scrutiny, but made no mention of the legislation or the ability to take legal action under the extended statute.

3c. Columbia does mention the legislation (finally) in a letter to patients that is not dated, but presumably sent between Sept 2023 and November 2023, giving patients less than 2 months to process and act (instead of the 18 months they could have had if the letter had gone out the day the statute was signed).

4. Do patients have a right to know when they have experienced (potential or actual) harm while receiving healthcare? Yes.

5. Why does failure to notify patients of harm happen in healthcare? I’ve written about my experiences with infection control and harm during the largest healthcare associated COVID outbreak, and I worry some of the same factors were at play at Columbia.

5a. Cost Containment: The formal investigation into Columbia’s failure to stop Robert Hadden was recently published. Notable are the role hierarchy, culture, and retaliation play and how these factors contributed to a cover-up that allowed harm to continue in the name of containing cost (monetary and reputational). What has yet to be explained is Columbia’s failure over the last 4 years to take the simple steps necessary to notify patients of harm and their right to sue. The letter they finally sent in response to public and journalistic scrutiny encourages patients to avail themselves of a prearranged settlement fund and mentions litigation only at the end. A generous read of that letter may lead one to believe the intent is to save survivors the pain of a lawsuit while allowing them to access reparations. The other read is that risk managers are trying, even now, to contain costs.

5b. Conflicts of Interest: Risk management and patient safety can be co-housed within departments, and they can have the same executive leader. What does this mean? It means the same person who is responsible for individual patient safety is also responsible for managing institutional risk (reputational and financial). The American Society for Health Care Risk Management houses risk management and patient safety under the same conceptual umbrella. Kaiser Permanente, one of the largest integrated healthcare organizations in the US takes this approach as well and has published their experience. This lack of distinction between the often divergent goals of patient safety and risk management, especially given corporate healthcare’s focus on revenue generation and cost containment, deprioritizes individual patients in favor of protecting the institution.

5c. Outdated ideas about patients, their rights, and their capacity to comprehend also drive failure to notify patients of safety events: A commonly used framework for assessing infection control risk provides a way to compare risk of familiar events to risk of infection after a disease exposure within healthcare. For example, when disclosing the risk of hepatitis C transmission to a patient after an instrument reprocessing failure, one could compare the risk of acquiring Hepatitis C from this event to the risk of a car accident to make the risk more understandable. Unfortunately, this framework is also used to justify lack of disclosure, with the convenient (if incorrect) rationale that the risk of distress from a disclosure is higher than the risk of disease transmission. This outdated and paternalistic approach centers controlling institutional risk over patient rights.

6. Does healthcare need an external governance structure for risk management and patient safety? Yes, until risk and accountability frameworks change.

6a. Protecting reputational risk at all costs: A culture of silence prevails at many healthcare organizations. Institutions have endless protocols and methods to obfuscate the truth. Incident reports are explicitly forbidden from being included in a patient’s medical record under the guise of confidentiality and safeguarding peer review processes. Reporting systems are clunky, often relying on paper forms or the IRIS reporting system which is outdated and imprecise. Investigations, when conducted, are done so by internal and/or biased investigators; external investigators and prosecutors are often undermined.

6b. Lack of accountability: There is little accountability for perpetrators or those who facilitate coverups. It is almost impossible to determine which individuals were responsible for the exceptionally dangerous decision making over the last 30 years we’ve seen come to light at Columbia University. Two long-time administrators will finally “leave their positions” this year. For those of us who have worked in patient safety and seen how the administrative machine works, it seems clear the maleficence was not limited to two individuals.

6c. Rethinking who we “promote” to administrative roles: What I keep coming back to is that doctors, in their administrative roles, were clearly involved in allowing Hadden to keep working and abusing women. Doctors perpetuated (administrative) harm. We have to rethink the way incentives work when anyone, including doctors, take on non-clinical roles. We also have to re-think who we promote to these roles and whether we think they are able to remain connected to the core values of healing.

I’m a doctor. So is Peter Attia. A few things about (t)his apology.

1. Attia states he asked Epstein about his 2008 conviction and believed Epstein’s characterization of it as prostitution related charges - he took him at face value.

a. Attia researches almost everything to the cellular level. Literally. Biologically. Like Rapamycin mTOR level detail.

b. It is not hard to find newspaper articles from 2008 in mainstream publications that characterize the GUILTY PLEA as related to soliciting CHILDREN for sex. Not underage women. Not minors. CHILDREN. The information is not buried and not hard to find.

c. I have a hard time reconciling 1a. and 1b.

2. Attia states he was not acting as Epstein’s personal physician. He just occasionally advised him or referred him to others.

a. Attia states he mostly met Epstein in social situations and in groups.

b. Attia states he and Epstein had no formal doctor patient relationship (though it is important to know that when you give anyone advice, you technically establish a doctor-patient relationship, which is protected by confidentiality rules unless abuse is transpiring, in which case doctors are mandated reporters).

c. There were >1700 email exchanges between the two.

d. I have a hard time reconciling 2a., 2b, and 2c.

3. Attia states the “shipment” he refers to was of Metformin.

3a. Doctors don’t usually get shipments of medications like Metformin to their offices unless they are in the form of samples from pharmaceutical companies (which we do hand out to patients).

3b. Rarer medications, like investigational study medications, are sometimes shipped to doctors offices.

3c. Doctors offices do sometimes dispense what we call directly observed oral therapy (like a single dose of an antibiotic) or an injection.

3d. The record keeping for 3b. and 3c. is different from regular doctor record keeping - dispensing is regulated differently and one has to be able to produce paperwork if investigated that shows tracking of inventory, etc.

3e. A shipment of Metformin is not exciting. It is not new, expensive, fancy, unusual. A 30 day supply is less than 5 dollars. It generates absolutely no excitement in most doctors.

3f. Same as 1c. and 2d.

4. He tried to get the survivors’ therapy directly paid for by their abuser?

5. Unrelated to his apology, but perhaps to be included in his next steps: I read his book, I follow his longevity work. There are real issues with longevity and health disparity in this country - access to nutritious food, safe space to move, age appropriate health screenings. I have yet to see him use his platform to advocate for moving the needle for population health or to close race and economic based heath outcome gaps.

6. The gig is NOT to let your judgement be clouded by the presence of “venerable people”. The gig is to do the job regardless of someone’s social standing, the size of their house or their plane, and their access to other people. Our responsibility is to call it out when those venerable people are blinded by their self-perceived exceptionalism while simultaneously making sure we don’t lose our vision.

Peter Attia didn’t complete residency and I don’t fault him for that in and of itself. But I do think residency and the early years of clinical practice inform how we are going “to be” as doctors - how we are going to be of service to all, and how we figure out a path forward rooted in justice when “venerable people” actively or passively take up all the air and resources. We learn pretty early in clinical practice that it doesn’t matter how much money you have or where you went to school - and that leading with that will not get you faster care because that isn’t actually what we signed up for when we went into medicine.

Sometimes the most dangerous policies are made by humans who seem like they should be great decision makers. These folks are confident, successful, smart. They have impressive workplace titles. They have long publication lists and pretty headshots. They have a lot of power. And, like all of us, they have blindspots. The confluence of blindspots, things that sound good, and influence is how we got to this week’s devastating Hepatitis B vaccine decision by the “new ACIP”.

Blindspot policy making in public health found its footing during the early days of COVID. Jay Bhattacharya, now the director of the NIH, published scientific and position papers in 2020 that advocated for less stringent COVID precautions and ignored several fundamental truths - a. that not all people have access to the type of routine medical care that would allow one to know about underlying risk factors like asthma, diabetes, or heart disease and b. that population heterogeneity rendered his data non-applicable to the rest of the county he worked in, let alone the rest of the country. A trip 15 miles south to my hospital from his hospital would have have made this clear. Is he a smart person with an impressive career? Yes. Did he have a blindspot about the relationship between emerging infectious diseases, disease susceptibility, and sociodemographic factors? Yes. Was this harmful? Also yes.

Had Dr. Bhattacharya traveled 15 miles south of Stanford, he would have arrived at my hospital, featured in an interview with JAMA editor-in-chief Howard Bauchner in March of 2020 because we had so many COVID patients. He would have seen the intubated young men with their undiagnosed diabetes living in multigenerational homes full of essential workers and understood that his ideas did not stand up to a walk through our hallways and that those men never went back home to their children. Blindspot.

Dr. Bauchner’s podcast in March of 2020 about my hospital also promoted the idea of “droplet mitigation”, and his journal published a paper on the same topic. This paper conflated community and hospital strategies for managing COVID-19, and inexplicably promoted the idea that it was appropriate to mitigate instead of contain this novel and deadly virus within the hospital setting. Certainly containment had failed by then in the community, but in a hospital, full of vulnerable and densely housed patients, the goal is always to contain infectious diseases. Part of this “hospital mitigation strategy” was to only allow healthcare workers to use droplet precautions for the routine care of COVID-19 patients and deny them N95 masks, further risking the health of patients (not to mention healthcare workers) and defying fundamental infection control principles for novel viruses. Why would someone successful enough to become the editor-in-chief of a leading medical journal promote such careless ideas about a novel virus? Because being really good at one thing does not make you know everything. Again, a blindspot.

That same JAMA podcast series came under fire in 2021 after publishing media content denying the existence of structural racism in medicine. The host of that episode, deputy editor Ed Livingston, appropriately (in my opinion) resigned in response to the criticism. Dr. Livingston has impressive credentials and a long list of publications. None of those publications are about racism or adjacent topics such as equity or bias. I don’t celebrate the consequences he faced, but I do wonder (as I do with Drs. Bhattacharya and Bauchner), why discuss such an important topic and take such a firm stand when you don’t have any of the necessary content expertise? Blindspot?

The CDC’s immunization committee voted this week to delay Hepatitis B vaccination until 2 months of age for most newborns. There are plenty of articles about the panel members and their backgrounds, and many talking heads who cite Canadian and European vaccine policy as evidence that the new US policy is safe. And then there are those who understand horizontal transmission of Hepatitis B, incomplete access to prenatal care, the difficulties of operationalizing 3rd trimester testing for high risk patients, and what chronic hepatitis B looks like at 30, 40, and 50. Who know what hepatocellular carcinoma and liver failure look like. Who know how hard it is to get a liver transplant and how that is not the end, but just the beginning. Those whose blindspots got erased while holding the jaundiced hand of an encephalopathic, edematous patient with an INR of 5 who needs a paracentesis.

Why do people who don’t understand the details, the nitty gritty, the nuance - why do they want to exert so much influence over policy? Why don’t their blindspots terrify them? Why do they want that responsibility and how do they not drown under the weight of the consequences of their decisions? I tell my patients that I know when they’ve turned the corner clinically because I no longer think about them at night - specifically I stop worrying that I’ve missed something. Who are these people who are so confident that they want to take on this kind of worry for an entire generation of newborn children?

References:

March 2020 JAMA Podcast Interview w H. Buchner

Bhattacharya WSJ Op-Ed

Bhattacharya Seroprevalence Study

Structural Racism in Medicine JAMA Podcast

CDC Hepatitis B Epidemiology

Droplet Mitigation Guidance for Hospitals

March 2020 JAMA Droplet Mitigation Article

I fell a little bit in love with many of my co-workers in 2020. In the most platonic of ways. Over video calls and bleary eyed 3am conversations. Teams chats. Through masks and faceshields and peanut butter cups, coffee, and stress. We were doing our best to take really good care of our community and each other, and that was palpable. We were connected, through late night meetings and early morning updates. There was profound respect for each other and our skill sets - nurses, environmental services, pharmacists, doctors, technology consultants - we problem solved and leveled up over and over.

By December of 2020, we had a lot of our clinical protocols worked out - high flow nasal cannula, anticoagulation, Remdesivir and dexamethasone. The protocols were detailed and tight - clear definitions of and risk factors for severe disease, resting and ambulatory O2 saturation cutoffs, renal and hepatic parameters for antivirals, and inflammatory marker cutoffs for immunomodulators. We built an amazing centralized repository for all clinical documents. It was something, to have sorted all of that out in less than a year.

It has taken me 5 years to understand what happened next. On Christmas Day, 2020, a healthcare worker came to work wearing an inflatable Christmas tree costume, and the largest healthcare associated COVID outbreak to date ensued.

The costume was not the cause of the outbreak - we knew that early on. The CDPH and CDC investigated, and their findings are available as part of a news story that was published a few months later. In short, they found systems based failures - confusing regional and national PPE guidelines, nonadherence to CDPH mandated employee testing, and no work restrictions for healthcare workers who were exposed to COVID in the community. No single individual working that day caused the outbreak. Instead, a large number of healthcare workers who didn’t know they were infected because they were largely presymptomatic inadvertently infected others. A lot people got sick. I spent a lot of time thinking about what I could have done differently.

I had a vantage point within my hospital and health system that let me be really proud of the clinical pieces we had gotten right in 2020, but also deeply concerned about the way certain organization wide decisions were being made. I took my concerns to my regional leadership in 2022. The 14 months between the outbreak and formally raising what kept me up at night allowed me to get some distance, neutrality, and steadiness from the responsibility I felt. My best friends read the six page letter I wrote to make sure it sounded like me. I prepared hundreds of Power Point slides and a master spreadsheet referencing thousands of pages of emails with contact information of those who could be interviewed to provide source documents. I trusted that my board would help me figure out the truth, just as they had trusted me on a deeply personal level over the previous two years to figure out COVID. And so, when the independent investigation I asked for substantiated none of my concerns, I turned even further inward.

I cried so much. I went to a lot of therapy, and eventually stopped having panic attacks and thinking about whether I should drive my car into the concrete barrier on that sharp curve where 87S turns into 85S on my way to work. My friends took me for introvert excursions around Almaden lake, stared at the stars with me from their hottubs, trusted me with their kids, and tolerated long delays in message replies. My dad and I took walks after he moved back to the US and talked about creating change. My husband hugged me a lot, told me he was proud of me, and reminded me to eat. My sister told her kids that sometimes it is important to say what we believe even if other people don’t agree. I got really strong.

I’m still not sure where the truth lies, but I am better now. I didn’t leave medicine. Time has helped me realize that my story isn’t particularly rare or limited to healthcare. The way my colleagues in academia, government, entertainment, and technology engage when we talk about the interplay between personal accountability and organizational change leads me to believe the disconnect between governance structures and the people those structures claim to serve is universal.

Writing has been really helpful for me (mostly in my journal, and now a bit for consumption) and it turns out for some of you too. The courage to put stuff out there more broadly comes from my oldest best friend telling her daughter to start following me because I write really good articles - and so, my new substack below for those who have asked and prefer that medium (with no promises that I actually have the technology skills to make it work). A few references below as well.

https://silverlininglioness.substack.com/subscribe?params=%5Bobject%20Object%5D

The link to the CDC and CDPH investigation finding are within the body of the KTVU article, and can be found here: https://www.documentcloud.org/documents/21034440-kaiser-san-jose-after-xmas-outbreak/ and https://www.ktvu.com/news/christmas-costume-likely-not-sole-source-of-covid-kaiser-outbreak

I’ve spent much of the day thinking about what I want to say about this podcast, the audio/visual version of a two part piece on administrative harm my friend and colleague Dr. Mary Meyer and I coauthored in 2025.

I have a work journal from every year since 2002, the year I started residency. This evening, after feeding the dogs and watching my nieces’ peace concert videos, I pulled out my well-worn moleskin from 2020 to put myself back into that feeling-state from 5 years ago. I specifically tried to figure out the day we transitioned from believing that the pandemic was the portal Arundhati Roy told us it could be to knowing with certainty that the cracks had not, in fact, let any light in.

I think the walls and silos went back up for good in August of 2020. January through March are blurry, but I had this feeling of certainty that we were getting it as right as we could. In April, we had geriatricians saving residential facilities from collapse. In May, my colleagues taught me to prioritize testing for those taking part in BLM protests. I have notes about equity on most calendar pages from June. And by July I have meetings scheduled with public health officials about non-adherence to state and county recommendations for community and healthcare worker testing; a picture of a clinically well outpatient child’s medical card whose connected parents requested she jump the queue for testing at a time when administering COVID therapeutics to critically ill inpatients was being delayed due to reagent shortages; the names and record numbers of six asymptomatic adults connected to a hospital association who similarly asked to utilize our “NBA COVID TEST” for no definable clinical reason; and meetings that ultimately ended in deciding against factoring neighborhood deprivation index into allocation decisions for drugs that were in short supply. By the end of the year, we had requests to administer monoclonal antibodies intended for immunocompromised COVID-19 patients to members of a sports franchise (we said no).

Why does this matter now, half a decade later? Because medicine remains deeply broken for reasons that often have very little to do with patients or the frontline healthcare workers who take care of them.

Links to Administrative Harm - The Podcast Version, are below if you wish to listen.

· YouTube

· Apple Podcasts

· Spotify

Charu